- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.72 / $1,494.08 / $1,604.17
| Professional | | $979.72 | $1,494.08 | $1,604.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.40 / $1,237.69 / $1,854.80
| Professional | | $956.40 | $1,237.69 | $1,854.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.23 / $814.23 / $814.23
| Facility | | $814.23 | $814.23 | $814.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.49 / $1,773.24 / $2,122.42
| Professional | | $1,204.49 | $1,773.24 | $2,122.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.61 / $1,384.49 / $2,123.88
| Professional | | $1,196.61 | $1,384.49 | $2,123.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.72 / $1,494.08 / $1,604.17
| Professional | | $979.72 | $1,494.08 | $1,604.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.26 / $1,336.19 / $1,750.42
| Professional | | $936.26 | $1,336.19 | $1,750.42 |