- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.19 / $2,981.94 / $3,838.63
| Professional | | $2,215.19 | $2,981.94 | $3,838.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,499.29 / $12,441.62 / $14,029.50
| Facility | | $9,499.29 | $12,441.62 | $14,029.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,605.62 / $3,371.98 / $5,166.14
| Professional | | $2,605.62 | $3,371.98 | $5,166.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.00 / $699.00 / $2,847.56
| Facility | | $699.00 | $699.00 | $2,847.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.65 / $3,615.53 / $5,444.24
| Professional | | $2,132.65 | $3,615.53 | $5,444.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,802.43 / $3,609.30 / $5,647.93
| Professional | | $2,802.43 | $3,609.30 | $5,647.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.19 / $2,981.94 / $3,838.63
| Professional | | $2,215.19 | $2,981.94 | $3,838.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,430.16 / $3,489.31 / $4,886.51
| Professional | | $2,430.16 | $3,489.31 | $4,886.51 |