- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.09 / $1,027.43 / $1,817.69
| Professional | | $806.09 | $1,027.43 | $1,817.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.66 / $1,747.21 / $3,158.88
| Facility | | $483.66 | $1,747.21 | $3,158.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.14 / $1,612.18 / $2,196.60
| Professional | | $1,209.14 | $1,612.18 | $2,196.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $1,335.63
| Facility | | $1,335.63 | $1,335.63 | $1,335.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $975.01 / $2,393.63
| Professional | | $975.01 | $975.01 | $2,393.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.04 / $1,152.71 / $9,614.69
| Facility | | $594.04 | $1,152.71 | $9,614.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.84 / $920.18 / $1,386.11
| Professional | | $830.84 | $920.18 | $1,386.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.84 / $920.18 / $1,386.11
| Professional | | $830.84 | $920.18 | $1,386.11 |