- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.79 / $1,389.79 / $1,532.82
| Professional | | $1,389.79 | $1,389.79 | $1,532.82 |
- 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
- $1,308.50 / $1,443.07 / $2,215.10
| Professional | | $1,308.50 | $1,443.07 | $2,215.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.97 / $1,621.13 / $2,322.56
| Professional | | $1,324.97 | $1,621.13 | $2,322.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.58 / $1,551.41 / $2,379.94
| Professional | | $1,204.58 | $1,551.41 | $2,379.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.79 / $1,389.79 / $1,532.82
| Professional | | $1,389.79 | $1,389.79 | $1,532.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.50 / $1,565.88 / $2,146.90
| Professional | | $1,185.50 | $1,565.88 | $2,146.90 |