- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.20 / $1,082.40 / $1,914.94
| Professional | | $849.20 | $1,082.40 | $1,914.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $557.37 / $2,013.49 / $3,640.31
| Facility | | $557.37 | $2,013.49 | $3,640.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.41 / $1,857.88 / $2,531.36
| Professional | | $1,393.41 | $1,857.88 | $2,531.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.05 / $1,407.05 / $1,407.05
| Facility | | $1,407.05 | $1,407.05 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $2,521.50
| Professional | | $1,027.15 | $1,027.15 | $2,521.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.83 / $1,214.35 / $10,128.96
| Facility | | $625.83 | $1,214.35 | $10,128.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.28 / $969.40 / $1,460.26
| Professional | | $875.28 | $969.40 | $1,460.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.28 / $969.40 / $1,460.26
| Professional | | $875.28 | $969.40 | $1,460.26 |