- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,263.08 / $1,263.08
| Professional | | $645.61 | $1,263.08 | $1,263.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.57 / $1,685.57 / $1,685.57
| Professional | | $1,685.57 | $1,685.57 | $1,685.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,082.51
| Facility | | $173.31 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,082.51 / $1,114.99
| Professional | | $161.82 | $1,082.51 | $1,114.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.10 / $5,241.14 / $6,642.96
| Professional | | $1,867.10 | $5,241.14 | $6,642.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.38 / $1,004.06 / $1,310.98
| Professional | | $669.38 | $1,004.06 | $1,310.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.56 / $1,992.76 / $2,536.23
| Professional | | $1,798.56 | $1,992.76 | $2,536.23 |