- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $4,570.88
| Professional | | $1,995.26 | $2,454.71 | $4,570.88 |
- 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
- $1,905.46 / $3,162.28 / $5,128.61
| Professional | | $1,905.46 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $3,630.78
| Facility | | $691.83 | $691.83 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,818.38 / $5,128.61
| Professional | | $1,047.13 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,630.78 / $6,025.60
| Professional | | $2,344.23 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $6,456.54
| Professional | | $2,089.30 | $3,235.94 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $4,897.79
| Professional | | $2,089.30 | $3,090.30 | $4,897.79 |