- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.79 / $1,258.79 / $1,451.46
| Professional | | $1,258.79 | $1,258.79 | $1,451.46 |
- 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
- $1,185.39 / $1,307.83 / $2,005.37
| Professional | | $1,185.39 | $1,307.83 | $2,005.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.14 / $1,468.22 / $2,103.48
| Professional | | $1,184.14 | $1,468.22 | $2,103.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.53 / $1,404.52 / $2,154.60
| Professional | | $1,090.53 | $1,404.52 | $2,154.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.79 / $1,258.79 / $1,451.46
| Professional | | $1,258.79 | $1,258.79 | $1,451.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.53 / $1,456.19 / $2,149.50
| Professional | | $1,090.53 | $1,456.19 | $2,149.50 |