- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,995.26 / $3,467.37
| Professional | | $1,047.13 | $1,995.26 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,542.29 / $28,840.32 / $38,904.51
| Facility | | $27,542.29 | $28,840.32 | $38,904.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $3,467.37
| Professional | | $1,412.54 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $3,467.37
| Professional | | $1,862.09 | $2,187.76 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,951.21
| Professional | | $1,905.46 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,454.71 / $4,677.35
| Professional | | $1,778.28 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $2,951.21
| Professional | | $1,621.81 | $2,290.87 | $2,951.21 |