- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.15 / $2,697.33 / $2,697.33
| Professional | | $1,984.15 | $2,697.33 | $2,697.33 |
- 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
- $2,637.96 / $2,901.75 / $4,143.89
| Professional | | $2,637.96 | $2,901.75 | $4,143.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,261.76 / $3,085.88 / $4,753.04
| Professional | | $2,261.76 | $3,085.88 | $4,753.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,413.98 / $3,109.01 / $4,769.39
| Professional | | $2,413.98 | $3,109.01 | $4,769.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.15 / $2,697.33 / $2,697.33
| Professional | | $1,984.15 | $2,697.33 | $2,697.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.54 / $3,186.94 / $4,346.08
| Professional | | $2,266.54 | $3,186.94 | $4,346.08 |