- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,774.87 / $1,774.87 / $2,184.84
| Professional | | $1,774.87 | $1,774.87 | $2,184.84 |
- 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
- $1,869.20 / $2,125.96 / $3,139.03
| Professional | | $1,869.20 | $2,125.96 | $3,139.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.34 / $2,177.34 / $3,275.19
| Professional | | $1,714.34 | $2,177.34 | $3,275.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.74 / $2,284.42 / $3,504.43
| Professional | | $1,773.74 | $2,284.42 | $3,504.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.08 / $1,774.87 / $2,184.84
| Professional | | $1,496.08 | $1,774.87 | $2,184.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.32 / $2,207.96 / $3,034.64
| Professional | | $1,540.32 | $2,207.96 | $3,034.64 |