- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $3,090.30
| Professional | | $1,318.26 | $1,659.59 | $3,090.30 |
- 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
- $1,318.26 / $2,089.30 / $2,884.03
| Professional | | $1,318.26 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,862.09 / $3,090.30
| Professional | | $1,698.24 | $1,862.09 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,818.38
| Professional | | $1,698.24 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $4,265.80
| Professional | | $1,318.26 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $3,019.95
| Professional | | $1,548.82 | $1,995.26 | $3,019.95 |