- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.95 / $1,211.95 / $1,358.15
| Professional | | $1,211.95 | $1,211.95 | $1,358.15 |
- 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
- $1,141.24 / $1,257.23 / $1,931.83
| Professional | | $1,141.24 | $1,257.23 | $1,931.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.54 / $1,353.01 / $2,075.59
| Professional | | $1,050.54 | $1,353.01 | $2,075.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.95 / $1,211.95 / $1,358.15
| Professional | | $1,211.95 | $1,211.95 | $1,358.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.50 / $1,386.60 / $1,872.37
| Professional | | $950.50 | $1,386.60 | $1,872.37 |