- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.13 / $1,639.13 / $1,847.45
| Professional | | $1,639.13 | $1,639.13 | $1,847.45 |
- 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
- $1,536.10 / $1,701.15 / $2,599.14
| Professional | | $1,536.10 | $1,701.15 | $2,599.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.67 / $1,904.95 / $2,729.17
| Professional | | $1,537.67 | $1,904.95 | $2,729.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.44 / $1,820.39 / $2,792.57
| Professional | | $1,413.44 | $1,820.39 | $2,792.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.13 / $1,639.13 / $1,847.45
| Professional | | $1,639.13 | $1,639.13 | $1,847.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.57 / $2,010.86 / $2,518.85
| Professional | | $1,547.57 | $2,010.86 | $2,518.85 |