- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.49 / $1,951.19 / $1,951.19
| Professional | | $1,608.49 | $1,951.19 | $1,951.19 |
- 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
- $1,359.33 / $1,668.04 / $2,481.76
| Professional | | $1,359.33 | $1,668.04 | $2,481.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.55 / $1,951.19 / $2,726.97
| Professional | | $1,642.55 | $1,951.19 | $2,726.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.47 / $1,592.33 / $2,477.67
| Professional | | $1,430.47 | $1,592.33 | $2,477.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.49 / $1,951.19 / $1,951.19
| Professional | | $1,608.49 | $1,951.19 | $1,951.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.12 / $1,880.88 / $2,270.03
| Professional | | $1,451.12 | $1,880.88 | $2,270.03 |