- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.01 / $1,814.33 / $1,814.33
| Professional | | $1,386.01 | $1,814.33 | $1,814.33 |
- 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
- $1,209.66 / $1,483.23 / $2,292.28
| Professional | | $1,209.66 | $1,483.23 | $2,292.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.49 / $1,814.33 / $2,426.10
| Professional | | $1,462.49 | $1,814.33 | $2,426.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.98 / $1,415.91 / $2,203.16
| Professional | | $1,271.98 | $1,415.91 | $2,203.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.01 / $1,814.33 / $1,814.33
| Professional | | $1,386.01 | $1,814.33 | $1,814.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.98 / $1,728.47 / $2,086.09
| Professional | | $1,292.98 | $1,728.47 | $2,086.09 |