- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.83 / $1,651.54 / $1,709.16
| Professional | | $1,253.83 | $1,651.54 | $1,709.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.21 / $1,503.49 / $1,503.49
| Professional | | $1,383.21 | $1,503.49 | $1,503.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $2,253.16
| Facility | | $171.39 | $1,071.00 | $2,253.16 |
- 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 / $938.32 / $1,424.03
| Professional | | $648.02 | $938.32 | $1,424.03 |