- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.45 / $1,679.88 / $1,679.88
| Professional | | $1,264.45 | $1,679.88 | $1,679.88 |
- 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
- $1,664.21 / $1,896.38 / $2,739.28
| Professional | | $1,664.21 | $1,896.38 | $2,739.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.64 / $2,051.30 / $3,101.21
| Professional | | $1,710.64 | $2,051.30 | $3,101.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.70 / $2,060.27 / $3,160.56
| Professional | | $1,599.70 | $2,060.27 | $3,160.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.45 / $1,679.88 / $1,679.88
| Professional | | $1,264.45 | $1,679.88 | $1,679.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.37 / $2,046.36 / $2,852.76
| Professional | | $1,453.37 | $2,046.36 | $2,852.76 |