- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $944.50 / $1,592.27 / $22,871.70
| Facility | | $944.50 | $1,592.27 | $22,871.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.75 / $3,878.77 / $24,178.50
| Professional | | $1,104.75 | $3,878.77 | $24,178.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,470.18 / $17,470.18 / $20,964.23
| Facility | | $17,470.18 | $17,470.18 | $20,964.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.63 / $1,049.45 / $14,913.62
| Professional | | $713.63 | $1,049.45 | $14,913.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,180.00 / $17,180.00 / $17,180.00
| Facility | | $17,180.00 | $17,180.00 | $17,180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,307.24 / $17,312.27 / $25,882.34
| Professional | | $12,307.24 | $17,312.27 | $25,882.34 |