- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.26 / $3,322.88 / $3,322.88
| Professional | | $1,446.26 | $3,322.88 | $3,322.88 |
- 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
- $2,324.03 / $2,864.55 / $4,199.84
| Professional | | $2,324.03 | $2,864.55 | $4,199.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.43 / $3,322.88 / $4,699.67
| Professional | | $1,551.43 | $3,322.88 | $4,699.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.57 / $2,734.53 / $4,254.93
| Professional | | $2,456.57 | $2,734.53 | $4,254.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.26 / $3,322.88 / $3,322.88
| Professional | | $1,446.26 | $3,322.88 | $3,322.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.32 / $3,089.62 / $4,270.92
| Professional | | $1,834.32 | $3,089.62 | $4,270.92 |