- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,344.23
| Professional | | $977.24 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,782.79 / $18,620.87 / $25,118.86
| Facility | | $17,782.79 | $18,620.87 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,089.30
| Professional | | $933.25 | $1,479.11 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $2,344.23
| Professional | | $1,202.26 | $1,348.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $2,089.30
| Professional | | $1,148.15 | $1,412.54 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,951.21
| Professional | | $977.24 | $1,230.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,089.30
| Professional | | $1,047.13 | $1,479.11 | $2,089.30 |