- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.33 / $2,155.33 / $2,568.44
| Professional | | $2,155.33 | $2,155.33 | $2,568.44 |
- 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
- $2,286.48 / $2,579.60 / $3,806.15
| Professional | | $2,286.48 | $2,579.60 | $3,806.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.73 / $2,640.06 / $3,966.83
| Professional | | $2,048.73 | $2,640.06 | $3,966.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.69 / $2,769.93 / $4,249.22
| Professional | | $2,150.69 | $2,769.93 | $4,249.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.21 / $2,155.33 / $2,568.44
| Professional | | $1,756.21 | $2,155.33 | $2,568.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.15 / $2,685.46 / $3,676.02
| Professional | | $1,972.15 | $2,685.46 | $3,676.02 |