- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,467.40 / $1,467.40
| Professional | | $1,077.57 | $1,467.40 | $1,467.40 |
- 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
- $1,431.00 / $1,583.84 / $2,287.80
| Professional | | $1,431.00 | $1,583.84 | $2,287.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.73 / $1,804.18 / $2,536.21
| Professional | | $1,457.73 | $1,804.18 | $2,536.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.78 / $1,721.66 / $2,641.12
| Professional | | $1,336.78 | $1,721.66 | $2,641.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,467.40 / $1,467.40
| Professional | | $1,077.57 | $1,467.40 | $1,467.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.54 / $1,681.64 / $2,386.80
| Professional | | $1,283.54 | $1,681.64 | $2,386.80 |