- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.70 / $1,867.70 / $2,103.30
| Professional | | $1,867.70 | $1,867.70 | $2,103.30 |
- 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
- $1,751.56 / $1,938.06 / $2,962.09
| Professional | | $1,751.56 | $1,938.06 | $2,962.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $2,171.13 / $3,110.52
| Professional | | $1,751.72 | $2,171.13 | $3,110.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.81 / $2,074.58 / $3,182.52
| Professional | | $1,610.81 | $2,074.58 | $3,182.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.70 / $1,867.70 / $2,103.30
| Professional | | $1,867.70 | $1,867.70 | $2,103.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.49 / $2,283.15 / $3,722.23
| Professional | | $1,572.49 | $2,283.15 | $3,722.23 |