- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.69 / $2,176.46 / $2,176.46
| Professional | | $1,597.69 | $2,176.46 | $2,176.46 |
- 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
- $1,513.58 / $1,860.19 / $2,753.53
| Professional | | $1,513.58 | $1,860.19 | $2,753.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.72 / $2,176.46 / $3,066.28
| Professional | | $1,786.72 | $2,176.46 | $3,066.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.25 / $1,775.76 / $2,763.08
| Professional | | $1,595.25 | $1,775.76 | $2,763.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.69 / $2,176.46 / $2,176.46
| Professional | | $1,597.69 | $2,176.46 | $2,176.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.86 / $2,051.26 / $2,780.23
| Professional | | $1,486.86 | $2,051.26 | $2,780.23 |