- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,890.45
| Professional | | $1,659.59 | $1,949.84 | $3,890.45 |
- 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
- $1,621.81 / $2,630.27 / $3,467.37
| Professional | | $1,621.81 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $3,715.35
| Professional | | $1,698.24 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $3,548.13
| Professional | | $2,089.30 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $4,570.88
| Professional | | $1,698.24 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $3,630.78
| Professional | | $1,621.81 | $2,290.87 | $3,630.78 |