- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.53 / $2,181.13 / $2,181.13
| Professional | | $1,658.53 | $2,181.13 | $2,181.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,010.53 / $14,279.49 / $16,101.93
| Facility | | $11,010.53 | $14,279.49 | $16,101.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.59 / $1,808.94 / $2,800.31
| Professional | | $1,537.59 | $1,808.94 | $2,800.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.83 / $2,181.13 / $3,116.16
| Professional | | $1,783.83 | $2,181.13 | $3,116.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.50 / $1,622.42 / $2,524.48
| Professional | | $1,457.50 | $1,622.42 | $2,524.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.53 / $2,181.13 / $2,181.13
| Professional | | $1,658.53 | $2,181.13 | $2,181.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.86 / $2,062.84 / $2,667.47
| Professional | | $1,486.86 | $2,062.84 | $2,667.47 |