- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.29 / $2,532.14 / $2,532.14
| Professional | | $1,969.29 | $2,532.14 | $2,532.14 |
- 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
- $1,762.44 / $2,159.86 / $3,221.85
| Professional | | $1,762.44 | $2,159.86 | $3,221.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,129.90 / $2,532.14 / $3,533.26
| Professional | | $2,129.90 | $2,532.14 | $3,533.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.24 / $2,061.82 / $3,208.19
| Professional | | $1,852.24 | $2,061.82 | $3,208.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.29 / $2,532.14 / $2,532.14
| Professional | | $1,969.29 | $2,532.14 | $2,532.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.84 / $2,457.76 / $3,178.14
| Professional | | $1,915.84 | $2,457.76 | $3,178.14 |