- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.11 / $2,389.11 / $2,915.84
| Professional | | $2,389.11 | $2,389.11 | $2,915.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,990.11 / $32,409.51 / $36,545.83
| Facility | | $24,990.11 | $32,409.51 | $36,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.62 / $2,860.73 / $4,220.32
| Professional | | $2,519.62 | $2,860.73 | $4,220.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.54 / $2,928.40 / $4,403.62
| Professional | | $2,308.54 | $2,928.40 | $4,403.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,384.73 / $3,071.34 / $4,711.60
| Professional | | $2,384.73 | $3,071.34 | $4,711.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.11 / $2,389.11 / $2,915.84
| Professional | | $2,389.11 | $2,389.11 | $2,915.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.13 / $3,192.38 / $4,130.51
| Professional | | $2,276.13 | $3,192.38 | $4,130.51 |