- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.04 / $1,464.28 / $1,732.64
| Professional | | $385.04 | $1,464.28 | $1,732.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.74 / $402.06 / $510.62
| Professional | | $383.74 | $402.06 | $510.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.21 / $2,282.21 / $2,282.21
| Facility | | $2,282.21 | $2,282.21 | $2,282.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.40 / $880.11 / $2,424.71
| Professional | | $346.40 | $880.11 | $2,424.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.46 / $1,645.11 / $2,973.80
| Professional | | $956.46 | $1,645.11 | $2,973.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.07 / $1,887.42 / $2,925.95
| Professional | | $1,297.07 | $1,887.42 | $2,925.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.28 / $1,275.28 / $1,798.22
| Professional | | $1,275.28 | $1,275.28 | $1,798.22 |