- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.08 / $1,334.08 / $1,350.96
| Professional | | $1,334.08 | $1,334.08 | $1,350.96 |
- 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
- $1,524.02 / $1,733.30 / $2,701.86
| Professional | | $1,524.02 | $1,733.30 | $2,701.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.77 / $1,961.88 / $2,802.29
| Professional | | $1,471.77 | $1,961.88 | $2,802.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.54 / $1,886.20 / $2,893.53
| Professional | | $1,464.54 | $1,886.20 | $2,893.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.08 / $1,334.08 / $1,350.96
| Professional | | $1,334.08 | $1,334.08 | $1,350.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.77 / $1,870.74 / $2,568.26
| Professional | | $1,281.77 | $1,870.74 | $2,568.26 |