- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,905.46 / $4,365.16
| Professional | | $1,621.81 | $1,905.46 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $26,915.35 / $36,307.81
| Facility | | $25,703.96 | $26,915.35 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,570.40 / $3,311.31
| Professional | | $1,548.82 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $3,548.13
| Professional | | $1,698.24 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,388.44
| Professional | | $1,995.26 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $4,570.88
| Professional | | $1,659.59 | $2,238.72 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,344.23 / $3,548.13
| Professional | | $1,584.89 | $2,344.23 | $3,548.13 |