- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.78 / $1,335.78 / $1,503.89
| Professional | | $1,335.78 | $1,335.78 | $1,503.89 |
- 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
- $1,251.40 / $1,384.55 / $2,117.73
| Professional | | $1,251.40 | $1,384.55 | $2,117.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.92 / $1,550.04 / $2,220.69
| Professional | | $1,251.92 | $1,550.04 | $2,220.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.63 / $1,483.20 / $2,275.32
| Professional | | $1,151.63 | $1,483.20 | $2,275.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.78 / $1,335.78 / $1,503.89
| Professional | | $1,335.78 | $1,335.78 | $1,503.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.86 / $1,545.48 / $2,060.64
| Professional | | $1,115.86 | $1,545.48 | $2,060.64 |