- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.83 / $1,784.36 / $1,824.30
| Professional | | $1,347.83 | $1,784.36 | $1,824.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.98 / $1,685.57 / $1,685.57
| Professional | | $1,431.98 | $1,685.57 | $1,685.57 |
- 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
- $173.31 / $920.13 / $1,082.51
| Professional | | $173.31 | $920.13 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.98 / $1,310.98 / $1,310.98
| Professional | | $1,310.98 | $1,310.98 | $1,310.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.29 / $1,056.11 / $1,419.42
| Professional | | $731.29 | $1,056.11 | $1,419.42 |