- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.84 / $2,166.02 / $2,166.02
| Professional | | $1,658.84 | $2,166.02 | $2,166.02 |
- 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
- $1,501.23 / $1,832.99 / $2,752.12
| Professional | | $1,501.23 | $1,832.99 | $2,752.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.62 / $2,166.02 / $3,019.41
| Professional | | $1,775.62 | $2,166.02 | $3,019.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.92 / $1,749.79 / $2,722.67
| Professional | | $1,571.92 | $1,749.79 | $2,722.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.84 / $2,166.02 / $2,166.02
| Professional | | $1,658.84 | $2,166.02 | $2,166.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.92 / $2,071.92 / $2,500.61
| Professional | | $1,571.92 | $2,071.92 | $2,500.61 |