- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $4,265.80
| Professional | | $1,737.80 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $22,387.21 / $30,199.52
| Facility | | $21,379.62 | $22,387.21 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $3,715.35
| Professional | | $1,698.24 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $4,265.80
| Professional | | $1,905.46 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,801.89
| Professional | | $2,089.30 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $5,370.32
| Professional | | $1,737.80 | $2,630.27 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $3,801.89
| Professional | | $1,862.09 | $2,754.23 | $3,801.89 |