- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $4,570.88
| Professional | | $1,548.82 | $1,905.46 | $4,570.88 |
- 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
- $1,698.24 / $2,630.27 / $3,715.35
| Professional | | $1,698.24 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,715.35
| Professional | | $1,819.70 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $4,677.35
| Professional | | $2,089.30 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $5,623.41
| Professional | | $1,659.59 | $2,187.76 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,715.35
| Professional | | $1,479.11 | $2,187.76 | $3,715.35 |