- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,737.80 / $3,090.30
| Professional | | $933.25 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $12,022.64 / $16,218.10
| Facility | | $11,220.18 | $12,022.64 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $3,090.30
| Professional | | $1,258.93 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,090.30
| Professional | | $1,659.59 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,630.27
| Professional | | $1,698.24 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $4,265.80
| Professional | | $1,621.81 | $2,137.96 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $2,630.27
| Professional | | $1,445.44 | $1,949.84 | $2,630.27 |