- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.11 / $1,613.17 / $1,613.17
| Professional | | $1,195.11 | $1,613.17 | $1,613.17 |
- 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
- $1,589.15 / $1,757.20 / $2,495.10
| Professional | | $1,589.15 | $1,757.20 | $2,495.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.78 / $1,859.40 / $2,788.58
| Professional | | $1,602.78 | $1,859.40 | $2,788.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.87 / $1,877.61 / $2,880.36
| Professional | | $1,457.87 | $1,877.61 | $2,880.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.11 / $1,613.17 / $1,613.17
| Professional | | $1,195.11 | $1,613.17 | $1,613.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.63 / $2,065.01 / $2,536.98
| Professional | | $1,514.63 | $2,065.01 | $2,536.98 |