- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.94 / $2,412.41 / $2,412.41
| Professional | | $1,946.94 | $2,412.41 | $2,412.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,010.53 / $14,279.49 / $16,101.93
| Facility | | $11,010.53 | $14,279.49 | $16,101.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.78 / $2,058.39 / $3,331.61
| Professional | | $1,678.78 | $2,058.39 | $3,331.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.04 / $2,412.41 / $3,365.95
| Professional | | $2,029.04 | $2,412.41 | $3,365.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.22 / $1,964.96 / $3,057.48
| Professional | | $1,765.22 | $1,964.96 | $3,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.94 / $2,412.41 / $2,412.41
| Professional | | $1,946.94 | $2,412.41 | $2,412.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.97 / $2,492.07 / $3,045.80
| Professional | | $1,803.97 | $2,492.07 | $3,045.80 |