- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $4,073.80
| Professional | | $1,659.59 | $2,137.96 | $4,073.80 |
- 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
- $1,778.28 / $2,884.03 / $3,715.35
| Professional | | $1,778.28 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,398.83 / $4,073.80
| Professional | | $1,949.84 | $2,398.83 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $3,801.89
| Professional | | $2,290.87 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $4,897.79
| Professional | | $1,513.56 | $2,137.96 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $3,981.07
| Professional | | $1,819.70 | $2,630.27 | $3,981.07 |