- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.86 / $2,859.86 / $3,651.79
| Professional | | $2,859.86 | $2,859.86 | $3,651.79 |
- 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
- $2,862.18 / $3,217.86 / $4,781.28
| Professional | | $2,862.18 | $3,217.86 | $4,781.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,959.39 / $3,473.91 / $5,303.10
| Professional | | $2,959.39 | $3,473.91 | $5,303.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.71 / $3,479.57 / $5,337.85
| Professional | | $2,701.71 | $3,479.57 | $5,337.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.86 / $2,859.86 / $3,651.79
| Professional | | $2,859.86 | $2,859.86 | $3,651.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,747.25 / $3,573.03 / $4,852.41
| Professional | | $2,747.25 | $3,573.03 | $4,852.41 |