- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.71 / $2,174.46 / $2,174.46
| Professional | | $1,616.71 | $2,174.46 | $2,174.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,544.61 / $34,425.54 / $38,819.15
| Facility | | $26,544.61 | $34,425.54 | $38,819.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.05 / $1,857.17 / $2,755.65
| Professional | | $1,510.05 | $1,857.17 | $2,755.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.85 / $2,174.46 / $3,058.53
| Professional | | $1,670.85 | $2,174.46 | $3,058.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.66 / $1,772.87 / $2,758.59
| Professional | | $1,592.66 | $1,772.87 | $2,758.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.71 / $2,174.46 / $2,174.46
| Professional | | $1,616.71 | $2,174.46 | $2,174.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.06 / $2,053.65 / $2,478.54
| Professional | | $1,450.06 | $2,053.65 | $2,478.54 |