- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.46 / $2,684.31 / $2,684.31
| Professional | | $1,953.46 | $2,684.31 | $2,684.31 |
- 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
- $1,867.28 / $2,287.67 / $3,415.93
| Professional | | $1,867.28 | $2,287.67 | $3,415.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.38 / $2,684.31 / $3,743.08
| Professional | | $2,256.38 | $2,684.31 | $3,743.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.85 / $2,183.84 / $3,398.06
| Professional | | $1,961.85 | $2,183.84 | $3,398.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,953.46 / $2,684.31 / $2,684.31
| Professional | | $1,953.46 | $2,684.31 | $2,684.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.52 / $2,646.02 / $3,386.73
| Professional | | $2,075.52 | $2,646.02 | $3,386.73 |