- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.55 / $1,937.55 / $2,289.17
| Professional | | $1,937.55 | $1,937.55 | $2,289.17 |
- 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
- $2,048.44 / $2,323.86 / $3,432.62
| Professional | | $2,048.44 | $2,323.86 | $3,432.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.84 / $2,380.59 / $3,580.60
| Professional | | $1,737.84 | $2,380.59 | $3,580.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.63 / $2,498.08 / $3,832.19
| Professional | | $1,939.63 | $2,498.08 | $3,832.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.55 / $1,937.55 / $2,289.17
| Professional | | $1,937.55 | $1,937.55 | $2,289.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.88 / $2,425.79 / $3,593.77
| Professional | | $1,641.88 | $2,425.79 | $3,593.77 |