- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.61 / $1,167.06 / $1,356.27
| Professional | | $905.61 | $1,167.06 | $1,356.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,491.08 / $26,019.37 / $30,263.27
| Facility | | $20,491.08 | $26,019.37 | $30,263.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.89 / $1,477.75 / $2,083.07
| Professional | | $1,141.89 | $1,477.75 | $2,083.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.57 / $1,627.52 / $2,377.92
| Professional | | $1,108.57 | $1,627.52 | $2,377.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.43 / $1,564.76 / $2,400.42
| Professional | | $1,352.43 | $1,564.76 | $2,400.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.61 / $1,352.05 / $1,356.27
| Professional | | $905.61 | $1,352.05 | $1,356.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.44 / $1,563.44 / $2,189.12
| Professional | | $1,009.44 | $1,563.44 | $2,189.12 |