- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.90 / $2,827.47 / $2,827.47
| Professional | | $2,056.90 | $2,827.47 | $2,827.47 |
- 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
- $1,966.46 / $2,409.44 / $3,598.28
| Professional | | $1,966.46 | $2,409.44 | $3,598.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.09 / $2,827.47 / $3,941.66
| Professional | | $2,376.09 | $2,827.47 | $3,941.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.27 / $2,300.08 / $3,578.92
| Professional | | $2,066.27 | $2,300.08 | $3,578.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.90 / $2,827.47 / $2,827.47
| Professional | | $2,056.90 | $2,827.47 | $2,827.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,186.51 / $2,739.73 / $3,542.76
| Professional | | $2,186.51 | $2,739.73 | $3,542.76 |