- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.49 / $2,143.42 / $2,143.42
| Professional | | $1,609.49 | $2,143.42 | $2,143.42 |
- 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
- $1,490.28 / $1,829.96 / $2,732.70
| Professional | | $1,490.28 | $1,829.96 | $2,732.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.72 / $2,143.42 / $3,018.51
| Professional | | $1,732.72 | $2,143.42 | $3,018.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.33 / $1,746.90 / $2,718.18
| Professional | | $1,569.33 | $1,746.90 | $2,718.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.49 / $2,143.42 / $2,143.42
| Professional | | $1,609.49 | $2,143.42 | $2,143.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.48 / $1,970.00 / $2,547.41
| Professional | | $1,439.48 | $1,970.00 | $2,547.41 |