- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,981.07
| Professional | | $1,819.70 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,197.01 / $19,498.45 / $26,302.68
| Facility | | $18,197.01 | $19,498.45 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,754.23 / $3,715.35
| Professional | | $1,621.81 | $2,754.23 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $3,981.07
| Professional | | $2,041.74 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $3,630.78
| Professional | | $1,995.26 | $2,454.71 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $5,754.40
| Professional | | $1,862.09 | $2,511.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $3,630.78
| Professional | | $1,819.70 | $2,570.40 | $3,630.78 |