- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.79 / $3,194.44 / $3,194.44
| Professional | | $1,614.79 | $3,194.44 | $3,194.44 |
- 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
- $2,232.96 / $2,754.01 / $4,037.05
| Professional | | $2,232.96 | $2,754.01 | $4,037.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.82 / $3,194.44 / $4,515.35
| Professional | | $1,758.82 | $3,194.44 | $4,515.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.77 / $2,629.01 / $4,090.74
| Professional | | $2,361.77 | $2,629.01 | $4,090.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.79 / $3,194.44 / $3,194.44
| Professional | | $1,614.79 | $3,194.44 | $3,194.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,036.28 / $2,879.27 / $4,090.74
| Professional | | $2,036.28 | $2,879.27 | $4,090.74 |