- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.94 / $2,407.77 / $2,407.77
| Professional | | $1,770.94 | $2,407.77 | $2,407.77 |
- 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
- $2,350.50 / $2,585.55 / $3,698.14
| Professional | | $2,350.50 | $2,585.55 | $3,698.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.49 / $2,750.90 / $4,249.62
| Professional | | $2,011.49 | $2,750.90 | $4,249.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.66 / $2,773.75 / $4,255.07
| Professional | | $2,153.66 | $2,773.75 | $4,255.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.94 / $2,407.77 / $2,407.77
| Professional | | $1,770.94 | $2,407.77 | $2,407.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.15 / $3,018.50 / $3,883.73
| Professional | | $2,016.15 | $3,018.50 | $3,883.73 |