- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.33 / $1,412.33 / $1,626.84
| Professional | | $1,412.33 | $1,412.33 | $1,626.84 |
- 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
- $1,325.91 / $1,467.00 / $2,243.69
| Professional | | $1,325.91 | $1,467.00 | $2,243.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.11 / $1,642.66 / $2,353.40
| Professional | | $1,324.11 | $1,642.66 | $2,353.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.14 / $1,571.44 / $2,410.67
| Professional | | $1,220.14 | $1,571.44 | $2,410.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.33 / $1,412.33 / $1,626.84
| Professional | | $1,412.33 | $1,412.33 | $1,626.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.95 / $1,645.81 / $2,174.25
| Professional | | $1,165.95 | $1,645.81 | $2,174.25 |