- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.45 / $906.18 / $1,039.35
| Professional | | $905.45 | $906.18 | $1,039.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.30 / $897.30 / $1,461.70
| Facility | | $897.30 | $897.30 | $1,461.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.75 / $1,437.19 / $1,460.18
| Professional | | $1,149.75 | $1,437.19 | $1,460.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $991.68 / $2,482.92 / $4,806.31
| Facility | | $991.68 | $2,482.92 | $4,806.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.43 / $882.86 / $1,185.69
| Professional | | $441.43 | $882.86 | $1,185.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.16 / $146.18 / $146.18
| Facility | | $145.16 | $146.18 | $146.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.16 / $276.26 / $1,512.92
| Professional | | $145.16 | $276.26 | $1,512.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.42 / $882.86 / $1,185.69
| Professional | | $378.42 | $882.86 | $1,185.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.94 / $1,195.94 / $1,195.94
| Professional | | $1,195.94 | $1,195.94 | $1,195.94 |