- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.37 / $3,097.40 / $3,097.40
| Professional | | $2,537.37 | $3,097.40 | $3,097.40 |
- 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
- $2,153.19 / $2,637.86 / $3,941.58
| Professional | | $2,153.19 | $2,637.86 | $3,941.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.44 / $3,097.40 / $4,315.30
| Professional | | $2,549.44 | $3,097.40 | $4,315.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,262.16 / $2,518.13 / $3,918.21
| Professional | | $2,262.16 | $2,518.13 | $3,918.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,537.37 / $3,097.40 / $3,097.40
| Professional | | $2,537.37 | $3,097.40 | $3,097.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.50 / $3,128.69 / $3,776.01
| Professional | | $2,199.50 | $3,128.69 | $3,776.01 |