- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.85 / $1,237.85 / $2,123.30
| Professional | | $1,237.85 | $1,237.85 | $2,123.30 |
- 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
- $1,438.28 / $1,647.63 / $2,596.28
| Professional | | $1,438.28 | $1,647.63 | $2,596.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.73 / $1,854.10 / $2,656.32
| Professional | | $1,520.73 | $1,854.10 | $2,656.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.41 / $1,772.70 / $2,719.41
| Professional | | $1,376.41 | $1,772.70 | $2,719.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.85 / $1,237.85 / $2,123.30
| Professional | | $1,237.85 | $1,237.85 | $2,123.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.27 / $1,965.26 / $2,452.37
| Professional | | $1,304.27 | $1,965.26 | $2,452.37 |