- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.28 / $1,812.13 / $1,812.13
| Professional | | $1,386.28 | $1,812.13 | $1,812.13 |
- 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
- $1,261.21 / $1,547.13 / $2,306.52
| Professional | | $1,261.21 | $1,547.13 | $2,306.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.15 / $1,812.13 / $2,529.40
| Professional | | $1,400.15 | $1,812.13 | $2,529.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.78 / $1,476.91 / $2,298.07
| Professional | | $1,326.78 | $1,476.91 | $2,298.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.28 / $1,812.13 / $1,812.13
| Professional | | $1,386.28 | $1,812.13 | $1,812.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.58 / $1,806.59 / $2,290.59
| Professional | | $1,224.58 | $1,806.59 | $2,290.59 |