- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,507.21 / $3,257.32 / $3,257.32
| Professional | | $2,507.21 | $3,257.32 | $3,257.32 |
- 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
- $2,264.39 / $2,773.44 / $4,145.28
| Professional | | $2,264.39 | $2,773.44 | $4,145.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,679.63 / $3,257.32 / $4,537.63
| Professional | | $2,679.63 | $3,257.32 | $4,537.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.44 / $2,647.56 / $4,119.60
| Professional | | $2,378.44 | $2,647.56 | $4,119.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.00 / $2,507.21 / $3,257.32
| Professional | | $2,208.00 | $2,507.21 | $3,257.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.69 / $3,144.77 / $4,104.32
| Professional | | $2,279.69 | $3,144.77 | $4,104.32 |