- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,890.45
| Professional | | $1,584.89 | $1,905.46 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $22,387.21 / $30,199.52
| Facility | | $21,379.62 | $22,387.21 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,454.71 / $3,467.37
| Professional | | $1,513.56 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $3,890.45
| Professional | | $1,995.26 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,467.37
| Professional | | $1,862.09 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $5,128.61
| Professional | | $1,698.24 | $2,398.83 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $3,467.37
| Professional | | $1,819.70 | $2,511.89 | $3,467.37 |