- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.05 / $1,202.80 / $1,202.80
| Professional | | $888.05 | $1,202.80 | $1,202.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,409.70 / $26,469.21 / $29,847.38
| Facility | | $20,409.70 | $26,469.21 | $29,847.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.05 / $1,310.67 / $1,870.06
| Professional | | $1,191.05 | $1,310.67 | $1,870.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.64 / $1,478.85 / $2,087.73
| Professional | | $1,177.64 | $1,478.85 | $2,087.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.60 / $1,409.76 / $2,162.64
| Professional | | $1,094.60 | $1,409.76 | $2,162.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.05 / $1,202.80 / $1,202.80
| Professional | | $888.05 | $1,202.80 | $1,202.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.56 / $1,441.34 / $1,908.15
| Professional | | $1,007.56 | $1,441.34 | $1,908.15 |