- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,041.74 / $3,548.13
| Professional | | $1,148.15 | $2,041.74 | $3,548.13 |
- 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
- $1,445.44 / $2,344.23 / $3,548.13
| Professional | | $1,445.44 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $3,548.13
| Professional | | $2,089.30 | $2,238.72 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $2,951.21
| Professional | | $1,905.46 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $5,248.07
| Professional | | $1,862.09 | $2,630.27 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,090.30
| Professional | | $1,862.09 | $2,398.83 | $3,090.30 |