- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.46 / $953.68 / $1,009.14
| Professional | | $707.46 | $953.68 | $1,009.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.70 / $1,213.77 / $1,213.77
| Professional | | $1,031.70 | $1,213.77 | $1,213.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $171.39 / $1,071.00
| Facility | | $171.39 | $171.39 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.39 / $910.35 / $1,071.00
| Professional | | $171.39 | $910.35 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.62 / $1,019.67 / $1,699.45
| Professional | | $754.62 | $1,019.67 | $1,699.45 |