- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.46 / $2,436.46 / $2,652.77
| Professional | | $2,436.46 | $2,436.46 | $2,652.77 |
- 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
- $2,588.21 / $2,912.44 / $4,296.34
| Professional | | $2,588.21 | $2,912.44 | $4,296.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.32 / $2,979.36 / $4,477.77
| Professional | | $2,194.32 | $2,979.36 | $4,477.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.69 / $3,126.65 / $4,796.45
| Professional | | $2,427.69 | $3,126.65 | $4,796.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,436.46 / $2,436.46 / $2,652.77
| Professional | | $2,436.46 | $2,436.46 | $2,652.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.61 / $2,979.39 / $4,144.71
| Professional | | $2,036.61 | $2,979.39 | $4,144.71 |