- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.94 / $1,637.27 / $1,694.38
| Professional | | $1,202.94 | $1,637.27 | $1,694.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.35 / $1,490.60 / $1,490.60
| Professional | | $1,371.35 | $1,490.60 | $1,490.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $1,082.51 / $2,233.78
| Facility | | $173.31 | $1,082.51 | $2,233.78 |
- 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 / $923.96 / $1,411.66
| Professional | | $642.40 | $923.96 | $1,411.66 |