- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.40 / $2,238.05 / $2,238.05
| Professional | | $1,461.40 | $2,238.05 | $2,238.05 |
- 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
- $1,557.71 / $1,909.42 / $2,845.53
| Professional | | $1,557.71 | $1,909.42 | $2,845.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.90 / $2,238.05 / $3,124.12
| Professional | | $1,878.90 | $2,238.05 | $3,124.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.47 / $1,822.75 / $2,836.20
| Professional | | $1,637.47 | $1,822.75 | $2,836.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.40 / $1,846.65 / $2,238.05
| Professional | | $1,461.40 | $1,846.65 | $2,238.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.43 / $2,204.92 / $2,589.19
| Professional | | $1,669.43 | $2,204.92 | $2,589.19 |