- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.84 / $1,460.84 / $1,642.57
| Professional | | $1,460.84 | $1,460.84 | $1,642.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,783.47 / $23,063.27 / $26,006.75
| Facility | | $17,783.47 | $23,063.27 | $26,006.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.08 / $1,518.06 / $2,319.96
| Professional | | $1,372.08 | $1,518.06 | $2,319.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.10 / $1,699.63 / $2,435.02
| Professional | | $1,365.10 | $1,699.63 | $2,435.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.60 / $1,624.86 / $2,492.62
| Professional | | $1,261.60 | $1,624.86 | $2,492.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.34 / $1,460.84 / $1,642.57
| Professional | | $1,118.34 | $1,460.84 | $1,642.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.49 / $1,677.26 / $2,249.32
| Professional | | $1,206.49 | $1,677.26 | $2,249.32 |