- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.67 / $2,169.33 / $2,169.33
| Professional | | $1,778.67 | $2,169.33 | $2,169.33 |
- 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
- $1,507.95 / $1,847.67 / $2,761.16
| Professional | | $1,507.95 | $1,847.67 | $2,761.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.27 / $2,169.33 / $3,023.59
| Professional | | $1,756.27 | $2,169.33 | $3,023.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.51 / $1,763.80 / $2,744.47
| Professional | | $1,584.51 | $1,763.80 | $2,744.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.67 / $2,169.33 / $2,169.33
| Professional | | $1,778.67 | $2,169.33 | $2,169.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.28 / $2,137.71 / $2,736.56
| Professional | | $1,500.28 | $2,137.71 | $2,736.56 |