- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.94 / $1,857.94 / $2,013.51
| Professional | | $1,857.94 | $1,857.94 | $2,013.51 |
- 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
- $1,783.20 / $1,961.52 / $3,024.74
| Professional | | $1,783.20 | $1,961.52 | $3,024.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.35 / $2,193.89 / $3,143.12
| Professional | | $1,567.35 | $2,193.89 | $3,143.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.87 / $2,118.46 / $3,249.82
| Professional | | $1,644.87 | $2,118.46 | $3,249.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.94 / $1,857.94 / $2,013.51
| Professional | | $1,857.94 | $1,857.94 | $2,013.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.01 / $2,004.57 / $2,863.04
| Professional | | $1,440.01 | $2,004.57 | $2,863.04 |