- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $2,951.21
| Professional | | $1,318.26 | $1,584.89 | $2,951.21 |
- 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
- $1,202.26 / $2,041.74 / $2,818.38
| Professional | | $1,202.26 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,951.21
| Professional | | $1,548.82 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $2,630.27
| Professional | | $1,479.11 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $4,168.69
| Professional | | $1,318.26 | $1,819.70 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,630.27
| Professional | | $1,318.26 | $1,905.46 | $2,630.27 |