- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,424.77 / $2,424.77 / $2,863.69
| Professional | | $2,424.77 | $2,424.77 | $2,863.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,694.09 / $26,838.03 / $30,263.27
| Facility | | $20,694.09 | $26,838.03 | $30,263.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.28 / $3,345.96 / $4,833.14
| Professional | | $2,799.28 | $3,345.96 | $4,833.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,109.29 / $3,599.90 / $5,545.40
| Professional | | $3,109.29 | $3,599.90 | $5,545.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,813.54 / $3,623.61 / $5,558.81
| Professional | | $2,813.54 | $3,623.61 | $5,558.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,424.77 / $2,424.77 / $2,863.69
| Professional | | $2,424.77 | $2,424.77 | $2,863.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,498.06 / $3,434.48 / $5,067.52
| Professional | | $2,498.06 | $3,434.48 | $5,067.52 |