- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.86 / $1,405.38 / $1,405.38
| Professional | | $1,095.86 | $1,405.38 | $1,405.38 |
- 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
- $979.52 / $1,201.69 / $1,785.45
| Professional | | $979.52 | $1,201.69 | $1,785.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.71 / $1,405.38 / $1,966.96
| Professional | | $1,185.71 | $1,405.38 | $1,966.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.54 / $1,147.15 / $1,784.97
| Professional | | $1,030.54 | $1,147.15 | $1,784.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.86 / $1,405.38 / $1,405.38
| Professional | | $1,095.86 | $1,405.38 | $1,405.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.51 / $1,373.67 / $1,657.88
| Professional | | $1,108.51 | $1,373.67 | $1,657.88 |