- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.81 / $1,021.86 / $2,338.48
| Professional | | $768.81 | $1,021.86 | $2,338.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.52 / $170.30 / $170.30
| Professional | | $149.52 | $170.30 | $170.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,217.05 / $2,685.94
| Professional | | $1,034.49 | $1,217.05 | $2,685.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,341.20 / $1,507.46 / $8,728.48
| Facility | | $1,341.20 | $1,507.46 | $8,728.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.48 / $1,131.73 / $1,771.59
| Professional | | $721.48 | $1,131.73 | $1,771.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.76 / $1,122.30 / $1,771.59
| Professional | | $800.76 | $1,122.30 | $1,771.59 |