- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.82 / $1,415.10 / $1,503.68
| Professional | | $1,176.82 | $1,415.10 | $1,503.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.83 / $183.18 / $2,009.22
| Facility | | $148.83 | $183.18 | $2,009.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $160.28 / $2,163.77
| Professional | | $148.83 | $160.28 | $2,163.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $2,163.85
| Facility | | $173.31 | $1,082.51 | $2,163.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,082.51 / $1,659.96
| Professional | | $161.82 | $1,082.51 | $1,659.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.38 / $1,432.38 / $1,432.38
| Professional | | $1,432.38 | $1,432.38 | $1,432.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.41 / $970.99 / $1,720.67
| Professional | | $804.41 | $970.99 | $1,720.67 |