- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.68 / $1,907.72 / $1,907.72
| Professional | | $1,789.68 | $1,907.72 | $1,907.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,990.11 / $32,409.51 / $36,545.83
| Facility | | $24,990.11 | $32,409.51 | $36,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,009.24 / $2,270.11 / $3,396.58
| Professional | | $2,009.24 | $2,270.11 | $3,396.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.74 / $2,362.75 / $3,544.25
| Professional | | $1,748.74 | $2,362.75 | $3,544.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,919.26 / $2,471.85 / $3,791.95
| Professional | | $1,919.26 | $2,471.85 | $3,791.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,789.68 / $1,907.72 / $1,907.72
| Professional | | $1,789.68 | $1,907.72 | $1,907.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.01 / $2,047.58 / $3,294.42
| Professional | | $1,588.01 | $2,047.58 | $3,294.42 |