- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.61 / $1,756.61 / $3,051.22
| Professional | | $1,756.61 | $1,756.61 | $3,051.22 |
- 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
- $2,036.33 / $2,343.56 / $3,670.56
| Professional | | $2,036.33 | $2,343.56 | $3,670.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.12 / $2,623.58 / $3,758.74
| Professional | | $2,122.12 | $2,623.58 | $3,758.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.93 / $2,506.19 / $3,844.63
| Professional | | $1,945.93 | $2,506.19 | $3,844.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.61 / $1,756.61 / $3,051.22
| Professional | | $1,756.61 | $1,756.61 | $3,051.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.63 / $2,513.01 / $3,464.59
| Professional | | $1,885.63 | $2,513.01 | $3,464.59 |