- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.17 / $2,368.78 / $2,368.78
| Professional | | $1,949.17 | $2,368.78 | $2,368.78 |
- 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
- $1,648.78 / $2,021.25 / $3,013.38
| Professional | | $1,648.78 | $2,021.25 | $3,013.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.64 / $2,368.78 / $3,305.93
| Professional | | $1,981.64 | $2,368.78 | $3,305.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.37 / $1,929.51 / $3,002.32
| Professional | | $1,733.37 | $1,929.51 | $3,002.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.17 / $2,368.78 / $2,368.78
| Professional | | $1,949.17 | $2,368.78 | $2,368.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.37 / $2,291.55 / $2,765.67
| Professional | | $1,733.37 | $2,291.55 | $2,765.67 |