- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.96 / $1,704.70 / $1,814.28
| Professional | | $1,298.96 | $1,704.70 | $1,814.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,516.89 / $10,516.89 / $13,062.45
| Facility | | $10,516.89 | $10,516.89 | $13,062.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,188.29 / $5,188.29 / $5,188.29
| Professional | | $5,188.29 | $5,188.29 | $5,188.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.13 / $2,560.03 / $3,223.72
| Professional | | $1,506.13 | $2,560.03 | $3,223.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.06 / $2,138.58 / $3,223.72
| Professional | | $1,493.06 | $2,138.58 | $3,223.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.36 / $1,991.79 / $5,886.13
| Professional | | $1,814.36 | $1,991.79 | $5,886.13 |