- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.46 / $715.41 / $1,102.13
| Professional | | $703.46 | $715.41 | $1,102.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,268.63 / $22,395.57 / $25,253.84
| Facility | | $17,268.63 | $22,395.57 | $25,253.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.39 / $931.39 / $1,362.01
| Professional | | $775.39 | $931.39 | $1,362.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.16 / $1,014.74 / $1,542.30
| Professional | | $837.16 | $1,014.74 | $1,542.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.96 / $1,018.69 / $1,562.73
| Professional | | $790.96 | $1,018.69 | $1,562.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.41 / $715.41 / $1,089.72
| Professional | | $715.41 | $715.41 | $1,089.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.10 / $1,003.62 / $1,414.07
| Professional | | $730.10 | $1,003.62 | $1,414.07 |