- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,229.10 / $2,229.10 / $2,533.42
| Professional | | $2,229.10 | $2,229.10 | $2,533.42 |
- 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
- $2,361.61 / $2,668.41 / $3,935.26
| Professional | | $2,361.61 | $2,668.41 | $3,935.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.46 / $2,731.03 / $4,109.25
| Professional | | $2,131.46 | $2,731.03 | $4,109.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.65 / $2,863.88 / $4,393.34
| Professional | | $2,223.65 | $2,863.88 | $4,393.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,229.10 / $2,229.10 / $2,533.42
| Professional | | $2,229.10 | $2,229.10 | $2,533.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.64 / $2,558.26 / $3,851.50
| Professional | | $2,059.64 | $2,558.26 | $3,851.50 |