- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.93 / $1,079.93 / $1,564.44
| Professional | | $1,079.93 | $1,079.93 | $1,564.44 |
- 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
- $1,018.32 / $1,120.15 / $1,724.14
| Professional | | $1,018.32 | $1,120.15 | $1,724.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.86 / $1,261.31 / $1,807.04
| Professional | | $1,002.86 | $1,261.31 | $1,807.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.60 / $1,207.55 / $1,852.45
| Professional | | $937.60 | $1,207.55 | $1,852.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.93 / $1,079.93 / $1,564.44
| Professional | | $1,079.93 | $1,079.93 | $1,564.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.51 / $1,283.94 / $1,672.78
| Professional | | $861.51 | $1,283.94 | $1,672.78 |