- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.77 / $2,536.39 / $2,536.39
| Professional | | $1,867.77 | $2,536.39 | $2,536.39 |
- 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
- $2,477.28 / $2,728.73 / $3,889.54
| Professional | | $2,477.28 | $2,728.73 | $3,889.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.30 / $2,893.62 / $4,471.12
| Professional | | $2,150.30 | $2,893.62 | $4,471.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.38 / $2,916.33 / $4,473.81
| Professional | | $2,264.38 | $2,916.33 | $4,473.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.77 / $2,536.39 / $2,536.39
| Professional | | $1,867.77 | $2,536.39 | $2,536.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.64 / $3,093.78 / $4,084.04
| Professional | | $2,137.64 | $3,093.78 | $4,084.04 |