- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.74 / $2,326.17 / $2,326.17
| Professional | | $1,704.74 | $2,326.17 | $2,326.17 |
- 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
- $1,613.13 / $1,974.19 / $2,949.27
| Professional | | $1,613.13 | $1,974.19 | $2,949.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.01 / $2,326.17 / $3,262.14
| Professional | | $1,915.01 | $2,326.17 | $3,262.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.01 / $1,884.58 / $2,932.41
| Professional | | $1,693.01 | $1,884.58 | $2,932.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.74 / $2,326.17 / $2,326.17
| Professional | | $1,704.74 | $2,326.17 | $2,326.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.32 / $2,427.60 / $2,946.23
| Professional | | $1,796.32 | $2,427.60 | $2,946.23 |