- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.04 / $1,465.04 / $1,486.04
| Professional | | $1,465.04 | $1,465.04 | $1,486.04 |
- 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
- $1,405.15 / $1,545.66 / $2,388.73
| Professional | | $1,405.15 | $1,545.66 | $2,388.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.86 / $1,731.83 / $2,481.15
| Professional | | $1,243.86 | $1,731.83 | $2,481.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.01 / $1,673.02 / $2,566.51
| Professional | | $1,299.01 | $1,673.02 | $2,566.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.04 / $1,465.04 / $1,486.04
| Professional | | $1,465.04 | $1,465.04 | $1,486.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.57 / $1,578.04 / $2,263.69
| Professional | | $1,128.57 | $1,578.04 | $2,263.69 |