- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.42 / $1,160.89 / $1,400.31
| Professional | | $928.42 | $1,160.89 | $1,400.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,238.91 / $14,271.05 / $16,598.74
| Facility | | $11,238.91 | $14,271.05 | $16,598.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.83 / $1,507.44 / $2,134.57
| Professional | | $1,164.83 | $1,507.44 | $2,134.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.14 / $1,680.37 / $2,393.11
| Professional | | $1,136.14 | $1,680.37 | $2,393.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.06 / $1,612.93 / $2,474.32
| Professional | | $1,394.06 | $1,612.93 | $2,474.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.42 / $1,282.90 / $1,400.31
| Professional | | $928.42 | $1,282.90 | $1,400.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.48 / $1,509.21 / $2,212.81
| Professional | | $1,066.48 | $1,509.21 | $2,212.81 |