- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.82 / $2,102.82 / $2,321.88
| Professional | | $2,102.82 | $2,102.82 | $2,321.88 |
- 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
- $1,970.64 / $2,186.01 / $3,333.20
| Professional | | $1,970.64 | $2,186.01 | $3,333.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.31 / $2,445.15 / $3,503.10
| Professional | | $1,989.31 | $2,445.15 | $3,503.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.62 / $2,334.50 / $3,581.25
| Professional | | $1,812.62 | $2,334.50 | $3,581.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.82 / $2,102.82 / $2,321.88
| Professional | | $2,102.82 | $2,102.82 | $2,321.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.52 / $2,578.92 / $3,228.59
| Professional | | $1,819.52 | $2,578.92 | $3,228.59 |