- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.75 / $1,596.70 / $1,878.72
| Professional | | $1,302.75 | $1,596.70 | $1,878.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,687.01 / $9,687.01 / $12,031.72
| Facility | | $9,687.01 | $9,687.01 | $12,031.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.35 / $2,473.48 / $4,251.80
| Professional | | $2,098.35 | $2,473.48 | $4,251.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.90 / $1,983.48 / $3,326.88
| Professional | | $1,362.90 | $1,983.48 | $3,326.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.70 / $1,959.08 / $3,326.88
| Professional | | $1,239.70 | $1,959.08 | $3,326.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.62 / $1,832.49 / $4,915.71
| Professional | | $1,618.62 | $1,832.49 | $4,915.71 |