- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $3,715.35
| Professional | | $1,202.26 | $2,137.96 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $12,022.64 / $16,218.10
| Facility | | $11,220.18 | $12,022.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,454.71 / $3,715.35
| Professional | | $1,548.82 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $3,715.35
| Professional | | $2,137.96 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,090.30
| Professional | | $1,995.26 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $5,623.41
| Professional | | $1,949.84 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $3,235.94
| Professional | | $1,995.26 | $2,511.89 | $3,235.94 |