- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.05 / $2,894.92 / $2,894.92
| Professional | | $2,288.05 | $2,894.92 | $2,894.92 |
- 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
- $2,015.18 / $2,468.60 / $3,855.62
| Professional | | $2,015.18 | $2,468.60 | $3,855.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.30 / $2,894.92 / $4,038.68
| Professional | | $2,419.30 | $2,894.92 | $4,038.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.01 / $2,356.55 / $3,666.79
| Professional | | $2,117.01 | $2,356.55 | $3,666.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,288.05 / $2,894.92 / $2,894.92
| Professional | | $2,288.05 | $2,894.92 | $2,894.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.84 / $2,892.27 / $3,653.86
| Professional | | $2,140.84 | $2,892.27 | $3,653.86 |