- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.23 / $1,704.51 / $1,828.02
| Professional | | $1,062.23 | $1,704.51 | $1,828.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.33 / $1,507.58 / $1,910.52
| Professional | | $1,207.33 | $1,507.58 | $1,910.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,221.04 / $1,436.52
| Professional | | $1,221.04 | $1,221.04 | $1,436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $259.52 / $1,508.30 / $11,644.83
| Facility | | $259.52 | $1,508.30 | $11,644.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.92 / $1,197.07 / $2,153.38
| Professional | | $847.92 | $1,197.07 | $2,153.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.92 / $1,183.47 / $2,105.44
| Professional | | $847.92 | $1,183.47 | $2,105.44 |