- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.57 / $2,925.57 / $3,607.66
| Professional | | $2,925.57 | $2,925.57 | $3,607.66 |
- 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
- $3,071.64 / $3,495.14 / $5,154.18
| Professional | | $3,071.64 | $3,495.14 | $5,154.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,892.46 / $3,574.99 / $5,375.06
| Professional | | $2,892.46 | $3,574.99 | $5,375.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,912.41 / $3,750.94 / $5,754.14
| Professional | | $2,912.41 | $3,750.94 | $5,754.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.62 / $2,925.57 / $3,607.66
| Professional | | $2,532.62 | $2,925.57 | $3,607.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.18 / $3,669.36 / $4,971.75
| Professional | | $2,754.18 | $3,669.36 | $4,971.75 |