- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.70 / $1,603.70 / $2,782.67
| Professional | | $1,603.70 | $1,603.70 | $2,782.67 |
- 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
- $1,864.60 / $2,138.46 / $3,353.45
| Professional | | $1,864.60 | $2,138.46 | $3,353.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.43 / $2,396.56 / $3,433.49
| Professional | | $1,934.43 | $2,396.56 | $3,433.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.81 / $2,289.67 / $3,512.47
| Professional | | $1,777.81 | $2,289.67 | $3,512.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.70 / $1,603.70 / $2,782.67
| Professional | | $1,603.70 | $1,603.70 | $2,782.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.14 / $2,454.73 / $3,167.04
| Professional | | $1,714.14 | $2,454.73 | $3,167.04 |