- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.14 / $1,220.40 / $1,220.40
| Professional | | $908.14 | $1,220.40 | $1,220.40 |
- 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
- $1,203.20 / $1,323.52 / $1,897.40
| Professional | | $1,203.20 | $1,323.52 | $1,897.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.69 / $1,500.49 / $2,117.76
| Professional | | $1,194.69 | $1,500.49 | $2,117.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.79 / $1,429.31 / $2,192.64
| Professional | | $1,109.79 | $1,429.31 | $2,192.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.14 / $1,220.40 / $1,220.40
| Professional | | $908.14 | $1,220.40 | $1,220.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.82 / $1,405.02 / $1,935.80
| Professional | | $1,016.82 | $1,405.02 | $1,935.80 |