- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.79 / $2,901.79 / $3,591.61
| Professional | | $2,901.79 | $2,901.79 | $3,591.61 |
- 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
- $2,978.14 / $3,463.81 / $5,108.95
| Professional | | $2,978.14 | $3,463.81 | $5,108.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,867.78 / $3,544.40 / $5,328.37
| Professional | | $2,867.78 | $3,544.40 | $5,328.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.86 / $3,718.03 / $5,703.66
| Professional | | $2,886.86 | $3,718.03 | $5,703.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.79 / $2,901.79 / $3,591.61
| Professional | | $2,901.79 | $2,901.79 | $3,591.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.16 / $3,618.50 / $4,932.84
| Professional | | $2,686.16 | $3,618.50 | $4,932.84 |