- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.96 / $1,323.96 / $1,491.02
| Professional | | $1,323.96 | $1,323.96 | $1,491.02 |
- 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
- $1,244.51 / $1,374.07 / $2,106.83
| Professional | | $1,244.51 | $1,374.07 | $2,106.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.86 / $1,541.64 / $2,208.67
| Professional | | $1,231.86 | $1,541.64 | $2,208.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.71 / $1,475.58 / $2,263.62
| Professional | | $1,145.71 | $1,475.58 | $2,263.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.96 / $1,323.96 / $1,491.02
| Professional | | $1,323.96 | $1,323.96 | $1,491.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.94 / $1,464.69 / $2,041.12
| Professional | | $1,088.94 | $1,464.69 | $2,041.12 |