- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.74 / $2,407.30 / $2,407.30
| Professional | | $1,783.74 | $2,407.30 | $2,407.30 |
- 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
- $1,671.02 / $2,053.64 / $3,051.09
| Professional | | $1,671.02 | $2,053.64 | $3,051.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.48 / $2,407.30 / $3,382.94
| Professional | | $1,844.48 | $2,407.30 | $3,382.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.15 / $1,960.42 / $3,050.41
| Professional | | $1,761.15 | $1,960.42 | $3,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.74 / $2,407.30 / $2,407.30
| Professional | | $1,783.74 | $2,407.30 | $2,407.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.26 / $2,299.54 / $2,775.31
| Professional | | $1,624.26 | $2,299.54 | $2,775.31 |