- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.14 / $1,637.14 / $2,007.72
| Professional | | $1,637.14 | $1,637.14 | $2,007.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,990.11 / $32,409.51 / $36,545.83
| Facility | | $24,990.11 | $32,409.51 | $36,545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.18 / $1,959.46 / $2,897.22
| Professional | | $1,691.18 | $1,959.46 | $2,897.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.08 / $2,008.73 / $3,018.88
| Professional | | $1,555.08 | $2,008.73 | $3,018.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.10 / $2,108.44 / $3,234.47
| Professional | | $1,637.10 | $2,108.44 | $3,234.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.14 / $1,637.14 / $2,007.72
| Professional | | $1,637.14 | $1,637.14 | $2,007.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.09 / $1,973.58 / $2,803.18
| Professional | | $1,484.09 | $1,973.58 | $2,803.18 |