- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.94 / $1,535.94 / $1,712.32
| Professional | | $1,535.94 | $1,535.94 | $1,712.32 |
- 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
- $1,457.85 / $1,603.63 / $2,415.96
| Professional | | $1,457.85 | $1,603.63 | $2,415.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.98 / $1,791.05 / $2,566.00
| Professional | | $1,420.98 | $1,791.05 | $2,566.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.82 / $1,692.10 / $2,595.77
| Professional | | $1,313.82 | $1,692.10 | $2,595.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.94 / $1,535.94 / $1,712.32
| Professional | | $1,535.94 | $1,535.94 | $1,712.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.89 / $1,778.79 / $2,383.07
| Professional | | $1,267.89 | $1,778.79 | $2,383.07 |