- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.33 / $2,678.33 / $3,285.51
| Professional | | $2,678.33 | $2,678.33 | $3,285.51 |
- 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
- $2,843.40 / $3,202.52 / $4,724.28
| Professional | | $2,843.40 | $3,202.52 | $4,724.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,618.63 / $3,276.89 / $4,928.82
| Professional | | $2,618.63 | $3,276.89 | $4,928.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,669.49 / $3,438.08 / $5,274.20
| Professional | | $2,669.49 | $3,438.08 | $5,274.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,678.33 / $2,678.33 / $3,285.51
| Professional | | $2,678.33 | $2,678.33 | $3,285.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,907.71 / $3,850.22 / $4,559.91
| Professional | | $2,907.71 | $3,850.22 | $4,559.91 |