- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.50 / $1,815.50 / $2,233.69
| Professional | | $1,815.50 | $1,815.50 | $2,233.69 |
- 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
- $1,921.87 / $2,176.78 / $3,215.04
| Professional | | $1,921.87 | $2,176.78 | $3,215.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.94 / $2,229.88 / $3,350.70
| Professional | | $1,729.94 | $2,229.88 | $3,350.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.69 / $2,339.73 / $3,589.29
| Professional | | $1,816.69 | $2,339.73 | $3,589.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.50 / $1,815.50 / $2,233.69
| Professional | | $1,815.50 | $1,815.50 | $2,233.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.43 / $2,279.60 / $3,109.78
| Professional | | $1,680.43 | $2,279.60 | $3,109.78 |