- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.16 / $1,494.52 / $1,494.52
| Professional | | $1,093.16 | $1,494.52 | $1,494.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,409.70 / $26,469.21 / $29,847.38
| Facility | | $20,409.70 | $26,469.21 | $29,847.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.30 / $1,619.53 / $2,314.53
| Professional | | $1,472.30 | $1,619.53 | $2,314.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.74 / $1,837.53 / $2,586.48
| Professional | | $1,453.74 | $1,837.53 | $2,586.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.45 / $1,743.12 / $2,674.05
| Professional | | $1,353.45 | $1,743.12 | $2,674.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.16 / $1,494.52 / $1,494.52
| Professional | | $1,093.16 | $1,494.52 | $1,494.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.68 / $1,849.19 / $2,355.55
| Professional | | $1,392.68 | $1,849.19 | $2,355.55 |