- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.48 / $2,952.48 / $3,607.21
| Professional | | $2,952.48 | $2,952.48 | $3,607.21 |
- 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
- $3,005.09 / $3,527.35 / $5,202.02
| Professional | | $3,005.09 | $3,527.35 | $5,202.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,901.85 / $3,607.79 / $5,426.00
| Professional | | $2,901.85 | $3,607.79 | $5,426.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.44 / $3,785.75 / $5,807.54
| Professional | | $2,939.44 | $3,785.75 | $5,807.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,952.48 / $2,952.48 / $3,607.21
| Professional | | $2,952.48 | $2,952.48 | $3,607.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,762.78 / $3,680.93 / $5,017.03
| Professional | | $2,762.78 | $3,680.93 | $5,017.03 |