- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.00 / $1,187.07 / $1,187.07
| Professional | | $915.00 | $1,187.07 | $1,187.07 |
- 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
- $1,115.07 / $1,234.66 / $1,948.32
| Professional | | $1,115.07 | $1,234.66 | $1,948.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.36 / $1,413.18 / $2,000.15
| Professional | | $1,055.36 | $1,413.18 | $2,000.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.39 / $1,342.51 / $2,059.48
| Professional | | $1,042.39 | $1,342.51 | $2,059.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.00 / $1,187.07 / $1,187.07
| Professional | | $915.00 | $1,187.07 | $1,187.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.46 / $1,455.54 / $1,831.66
| Professional | | $975.46 | $1,455.54 | $1,831.66 |