- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.76 / $1,468.12 / $1,468.12
| Professional | | $1,157.76 | $1,468.12 | $1,468.12 |
- 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
- $1,022.94 / $1,255.67 / $1,863.33
| Professional | | $1,022.94 | $1,255.67 | $1,863.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.86 / $1,468.12 / $2,053.48
| Professional | | $1,237.86 | $1,468.12 | $2,053.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.83 / $1,198.68 / $1,865.15
| Professional | | $1,076.83 | $1,198.68 | $1,865.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.76 / $1,468.12 / $1,468.12
| Professional | | $1,157.76 | $1,468.12 | $1,468.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.25 / $1,434.70 / $1,860.72
| Professional | | $1,164.25 | $1,434.70 | $1,860.72 |