- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $20,892.96
| Professional | | $1,148.15 | $1,412.54 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $1,479.11
| Professional | | $151.36 | $151.36 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $10,715.19
| Facility | | $758.58 | $1,071.52 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $14,791.08 / $28,840.32
| Professional | | $1,096.48 | $14,791.08 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $14,791.08
| Professional | | $1,047.13 | $1,047.13 | $14,791.08 |