- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.64 / $2,428.42 / $2,428.42
| Professional | | $1,794.64 | $2,428.42 | $2,428.42 |
- 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
- $1,686.20 / $2,080.84 / $3,056.56
| Professional | | $1,686.20 | $2,080.84 | $3,056.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.55 / $2,428.42 / $3,413.39
| Professional | | $1,842.55 | $2,428.42 | $3,413.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.48 / $1,986.39 / $3,090.82
| Professional | | $1,784.48 | $1,986.39 | $3,090.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.64 / $2,428.42 / $2,428.42
| Professional | | $1,794.64 | $2,428.42 | $2,428.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.93 / $2,280.01 / $2,948.29
| Professional | | $1,609.93 | $2,280.01 | $2,948.29 |