- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.55 / $1,518.04 / $1,518.04
| Professional | | $1,213.55 | $1,518.04 | $1,518.04 |
- 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
- $1,056.83 / $1,296.26 / $2,055.52
| Professional | | $1,056.83 | $1,296.26 | $2,055.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.11 / $1,518.04 / $2,120.26
| Professional | | $1,278.11 | $1,518.04 | $2,120.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.64 / $1,237.42 / $1,925.43
| Professional | | $1,111.64 | $1,237.42 | $1,925.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.55 / $1,518.04 / $1,518.04
| Professional | | $1,213.55 | $1,518.04 | $1,518.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.40 / $1,544.57 / $1,925.43
| Professional | | $1,245.40 | $1,544.57 | $1,925.43 |