- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.28 / $3,488.10 / $3,488.10
| Professional | | $1,743.28 | $3,488.10 | $3,488.10 |
- 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
- $2,439.46 / $3,005.76 / $4,406.47
| Professional | | $2,439.46 | $3,005.76 | $4,406.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.88 / $3,488.10 / $4,931.99
| Professional | | $1,892.88 | $3,488.10 | $4,931.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.66 / $2,869.32 / $4,464.66
| Professional | | $2,577.66 | $2,869.32 | $4,464.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.28 / $3,488.10 / $3,488.10
| Professional | | $1,743.28 | $3,488.10 | $3,488.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.90 / $3,589.20 / $4,480.06
| Professional | | $1,925.90 | $3,589.20 | $4,480.06 |