- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.33 / $1,630.33 / $1,855.13
| Professional | | $1,630.33 | $1,630.33 | $1,855.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,813.28 / $29,586.39 / $33,362.40
| Facility | | $22,813.28 | $29,586.39 | $33,362.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,181.14 / $2,621.89 / $3,829.77
| Professional | | $2,181.14 | $2,621.89 | $3,829.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.98 / $3,095.57 / $4,334.66
| Professional | | $2,427.98 | $3,095.57 | $4,334.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,248.46 / $2,895.83 / $4,442.35
| Professional | | $2,248.46 | $2,895.83 | $4,442.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.33 / $1,630.33 / $1,855.13
| Professional | | $1,630.33 | $1,630.33 | $1,855.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,246.42 / $2,869.50 / $3,973.59
| Professional | | $2,246.42 | $2,869.50 | $3,973.59 |