- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.98 / $2,128.89 / $2,418.57
| Professional | | $1,127.98 | $2,128.89 | $2,418.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,744.96 / $31,420.90 / $36,545.83
| Facility | | $24,744.96 | $31,420.90 | $36,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.33 / $2,669.80 / $3,420.60
| Professional | | $2,269.33 | $2,669.80 | $3,420.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.93 / $3,210.59 / $4,925.22
| Professional | | $2,774.93 | $3,210.59 | $4,925.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.98 / $2,128.89 / $2,418.57
| Professional | | $1,127.98 | $2,128.89 | $2,418.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.89 / $3,022.20 / $4,436.93
| Professional | | $2,121.89 | $3,022.20 | $4,436.93 |