- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.83 / $1,876.83 / $2,114.39
| Professional | | $1,876.83 | $1,876.83 | $2,114.39 |
- 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
- $1,760.46 / $1,950.94 / $2,976.39
| Professional | | $1,760.46 | $1,950.94 | $2,976.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.89 / $2,185.57 / $3,131.21
| Professional | | $1,759.89 | $2,185.57 | $3,131.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.58 / $2,084.60 / $3,197.89
| Professional | | $1,618.58 | $2,084.60 | $3,197.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.42 / $1,876.83 / $2,114.39
| Professional | | $1,603.42 | $1,876.83 | $2,114.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.77 / $2,173.26 / $3,204.87
| Professional | | $1,595.77 | $2,173.26 | $3,204.87 |