- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.66 / $1,799.85 / $1,840.30
| Professional | | $1,359.66 | $1,799.85 | $1,840.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.39 / $1,700.29 / $1,700.29
| Professional | | $1,444.39 | $1,700.29 | $1,700.29 |
- 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
- $171.39 / $910.35 / $1,318.54
| Professional | | $171.39 | $910.35 | $1,318.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.44 / $1,322.44 / $1,322.44
| Professional | | $1,322.44 | $1,322.44 | $1,322.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.68 / $1,081.88 / $1,431.82
| Professional | | $737.68 | $1,081.88 | $1,431.82 |