- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $2,454.71
| Professional | | $831.76 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,908.68 / $24,547.09 / $33,113.11
| Facility | | $22,908.68 | $24,547.09 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $1,995.26
| Professional | | $870.96 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,995.26
| Professional | | $1,000.00 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $2,454.71
| Professional | | $1,071.52 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,884.03
| Professional | | $891.25 | $1,230.27 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $1,905.46
| Professional | | $794.33 | $1,202.26 | $1,905.46 |