- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.75 / $987.75 / $1,124.22
| Professional | | $987.75 | $987.75 | $1,124.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,065.14 / $15,647.20 / $17,644.18
| Facility | | $12,065.14 | $15,647.20 | $17,644.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.50 / $1,034.91 / $1,576.38
| Professional | | $930.50 | $1,034.91 | $1,576.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.44 / $1,153.49 / $1,652.57
| Professional | | $919.44 | $1,153.49 | $1,652.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.24 / $1,104.06 / $1,693.68
| Professional | | $857.24 | $1,104.06 | $1,693.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.02 / $987.75 / $1,124.22
| Professional | | $847.02 | $987.75 | $1,124.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.10 / $1,171.23 / $1,529.04
| Professional | | $807.10 | $1,171.23 | $1,529.04 |