- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.20 / $1,604.17 / $1,798.83
| Professional | | $1,277.20 | $1,604.17 | $1,798.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,065.14 / $15,647.20 / $17,644.18
| Facility | | $12,065.14 | $15,647.20 | $17,644.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.21 / $1,663.43 / $2,563.05
| Professional | | $1,512.21 | $1,663.43 | $2,563.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.70 / $1,873.97 / $2,684.80
| Professional | | $1,487.70 | $1,873.97 | $2,684.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.81 / $1,795.11 / $2,753.79
| Professional | | $1,393.81 | $1,795.11 | $2,753.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.20 / $1,604.17 / $1,798.83
| Professional | | $1,277.20 | $1,604.17 | $1,798.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.84 / $1,772.23 / $2,483.82
| Professional | | $1,314.84 | $1,772.23 | $2,483.82 |