- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $5,011.87
| Professional | | $1,737.80 | $2,137.96 | $5,011.87 |
- 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
- $1,862.09 / $2,951.21 / $4,168.69
| Professional | | $1,862.09 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $4,168.69
| Professional | | $2,041.74 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $5,248.07
| Professional | | $2,344.23 | $2,754.23 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $6,309.57
| Professional | | $1,862.09 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $4,073.80
| Professional | | $1,659.59 | $2,454.71 | $4,073.80 |