- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.40 / $1,748.47 / $1,748.47
| Professional | | $1,312.40 | $1,748.47 | $1,748.47 |
- 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
- $1,725.63 / $1,915.52 / $2,709.38
| Professional | | $1,725.63 | $1,915.52 | $2,709.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.07 / $2,034.36 / $3,029.19
| Professional | | $1,741.07 | $2,034.36 | $3,029.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.40 / $2,039.29 / $3,128.39
| Professional | | $1,583.40 | $2,039.29 | $3,128.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.40 / $1,748.47 / $1,748.47
| Professional | | $1,312.40 | $1,748.47 | $1,748.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.40 / $2,084.16 / $3,128.39
| Professional | | $1,583.40 | $2,084.16 | $3,128.39 |