- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.72 / $1,718.96 / $1,820.07
| Professional | | $971.72 | $1,718.96 | $1,820.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.50 / $2,044.50 / $2,044.50
| Professional | | $2,044.50 | $2,044.50 | $2,044.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $1,071.00
| Facility | | $171.39 | $1,071.00 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $1,071.00 / $2,677.50
| Professional | | $163.22 | $1,071.00 | $2,677.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.02 / $970.09 / $1,578.62
| Professional | | $648.02 | $970.09 | $1,578.62 |