- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.45 / $2,511.04 / $2,511.04
| Professional | | $1,940.45 | $2,511.04 | $2,511.04 |
- 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
- $1,747.26 / $2,141.29 / $3,194.51
| Professional | | $1,747.26 | $2,141.29 | $3,194.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,109.46 / $2,511.04 / $3,503.00
| Professional | | $2,109.46 | $2,511.04 | $3,503.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.32 / $2,044.10 / $3,180.62
| Professional | | $1,836.32 | $2,044.10 | $3,180.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.45 / $2,511.04 / $2,511.04
| Professional | | $1,940.45 | $2,511.04 | $2,511.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.75 / $2,417.54 / $3,169.34
| Professional | | $1,886.75 | $2,417.54 | $3,169.34 |