- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $3,715.35
| Professional | | $1,513.56 | $1,698.24 | $3,715.35 |
- 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
- $1,584.89 / $2,511.89 / $3,388.44
| Professional | | $1,584.89 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $3,630.78
| Professional | | $1,698.24 | $2,137.96 | $3,630.78 |
- 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
- $1,659.59 / $2,137.96 / $4,570.88
| Professional | | $1,659.59 | $2,137.96 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $3,630.78
| Professional | | $1,584.89 | $2,089.30 | $3,630.78 |