- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.85 / $1,407.00 / $1,407.00
| Professional | | $1,169.85 | $1,407.00 | $1,407.00 |
- 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
- $980.22 / $1,203.43 / $1,786.84
| Professional | | $980.22 | $1,203.43 | $1,786.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.61 / $1,407.00 / $1,968.46
| Professional | | $1,186.61 | $1,407.00 | $1,968.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.03 / $1,148.80 / $1,787.53
| Professional | | $1,032.03 | $1,148.80 | $1,787.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.85 / $1,407.00 / $1,407.00
| Professional | | $1,169.85 | $1,407.00 | $1,407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.49 / $1,450.67 / $1,750.81
| Professional | | $1,077.49 | $1,450.67 | $1,750.81 |