- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,949.84 / $3,388.44
| Professional | | $1,047.13 | $1,949.84 | $3,388.44 |
- 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
- $1,380.38 / $2,187.76 / $3,388.44
| Professional | | $1,380.38 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $3,311.31
| Professional | | $1,949.84 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $2,818.38
| Professional | | $1,778.28 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $4,897.79
| Professional | | $1,778.28 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $2,951.21
| Professional | | $1,778.28 | $2,290.87 | $2,951.21 |