- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.44 / $1,518.44 / $1,712.70
| Professional | | $1,518.44 | $1,518.44 | $1,712.70 |
- 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
- $1,425.94 / $1,578.32 / $2,413.26
| Professional | | $1,425.94 | $1,578.32 | $2,413.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.53 / $1,767.07 / $2,531.64
| Professional | | $1,425.53 | $1,767.07 | $2,531.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.34 / $1,690.19 / $2,592.84
| Professional | | $1,312.34 | $1,690.19 | $2,592.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.44 / $1,518.44 / $1,712.70
| Professional | | $1,518.44 | $1,518.44 | $1,712.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.54 / $1,758.51 / $2,337.33
| Professional | | $1,269.54 | $1,758.51 | $2,337.33 |