- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.93 / $1,870.93 / $2,293.12
| Professional | | $1,870.93 | $1,870.93 | $2,293.12 |
- 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
- $1,936.98 / $2,246.91 / $3,319.25
| Professional | | $1,936.98 | $2,246.91 | $3,319.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.05 / $2,302.83 / $3,464.68
| Professional | | $1,733.05 | $2,302.83 | $3,464.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.57 / $2,415.57 / $3,705.62
| Professional | | $1,875.57 | $2,415.57 | $3,705.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.93 / $1,870.93 / $2,293.12
| Professional | | $1,870.93 | $1,870.93 | $2,293.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.07 / $2,279.11 / $3,214.35
| Professional | | $1,657.07 | $2,279.11 | $3,214.35 |