- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.40 / $1,559.40 / $1,761.54
| Professional | | $1,559.40 | $1,559.40 | $1,761.54 |
- 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
- $1,465.22 / $1,618.35 / $2,477.94
| Professional | | $1,465.22 | $1,618.35 | $2,477.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.34 / $1,816.16 / $2,601.96
| Professional | | $1,463.34 | $1,816.16 | $2,601.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.52 / $1,735.50 / $2,662.35
| Professional | | $1,347.52 | $1,735.50 | $2,662.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.40 / $1,559.40 / $1,761.54
| Professional | | $1,559.40 | $1,559.40 | $1,761.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.52 / $1,785.99 / $2,662.35
| Professional | | $1,347.52 | $1,785.99 | $2,662.35 |