- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.11 / $1,630.11 / $2,107.67
| Professional | | $1,630.11 | $1,630.11 | $2,107.67 |
- 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
- $1,689.95 / $1,919.98 / $2,836.93
| Professional | | $1,689.95 | $1,919.98 | $2,836.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.78 / $2,017.01 / $3,022.14
| Professional | | $1,684.78 | $2,017.01 | $3,022.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.03 / $2,064.56 / $3,167.15
| Professional | | $1,603.03 | $2,064.56 | $3,167.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.80 / $1,630.11 / $2,107.67
| Professional | | $1,497.80 | $1,630.11 | $2,107.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.88 / $2,084.87 / $2,810.73
| Professional | | $1,595.88 | $2,084.87 | $2,810.73 |