- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.92 / $2,887.92 / $3,014.22
| Professional | | $2,887.92 | $2,887.92 | $3,014.22 |
- 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
- $3,069.60 / $3,452.30 / $5,089.93
| Professional | | $3,069.60 | $3,452.30 | $5,089.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.50 / $3,530.88 / $5,308.33
| Professional | | $2,473.50 | $3,530.88 | $5,308.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,876.12 / $3,704.20 / $5,682.45
| Professional | | $2,876.12 | $3,704.20 | $5,682.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.92 / $2,887.92 / $3,014.22
| Professional | | $2,887.92 | $2,887.92 | $3,014.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.42 / $3,283.83 / $4,910.79
| Professional | | $2,233.42 | $3,283.83 | $4,910.79 |