- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.65 / $2,374.44 / $2,374.44
| Professional | | $1,744.65 | $2,374.44 | $2,374.44 |
- 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
- $2,320.46 / $2,552.51 / $3,647.27
| Professional | | $2,320.46 | $2,552.51 | $3,647.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.11 / $2,712.67 / $4,190.81
| Professional | | $1,997.11 | $2,712.67 | $4,190.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.67 / $2,735.11 / $4,195.81
| Professional | | $2,123.67 | $2,735.11 | $4,195.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.65 / $2,374.44 / $2,374.44
| Professional | | $1,744.65 | $2,374.44 | $2,374.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.61 / $2,975.92 / $3,830.85
| Professional | | $1,997.61 | $2,975.92 | $3,830.85 |