- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.70 / $791.70 / $791.70
| Professional | | $791.70 | $791.70 | $791.70 |
- 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
- $839.07 / $912.04 / $912.04
| Professional | | $839.07 | $912.04 | $912.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.10 / $723.10 / $723.10
| Professional | | $723.10 | $723.10 | $723.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.17 / $1,521.28 / $2,431.03
| Professional | | $1,240.17 | $1,521.28 | $2,431.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.70 / $791.70 / $791.70
| Professional | | $791.70 | $791.70 | $791.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.07 / $1,362.18 / $1,842.87
| Professional | | $1,157.07 | $1,362.18 | $1,842.87 |