- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $1,235.75 / $1,804.41
| Professional | | $645.61 | $1,235.75 | $1,804.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.22 / $1,812.22 / $1,812.22
| Professional | | $1,812.22 | $1,812.22 | $1,812.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $1,082.51
| Facility | | $173.31 | $1,082.51 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,082.51 / $2,655.00
| Professional | | $161.82 | $1,082.51 | $2,655.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.40 / $963.59 / $1,550.32
| Professional | | $642.40 | $963.59 | $1,550.32 |