- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.26 / $819.26 / $1,024.08
| Professional | | $819.26 | $819.26 | $1,024.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,803.64 / $1,803.64 / $1,803.64
| Facility | | $1,803.64 | $1,803.64 | $1,803.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.09 / $2,254.55 / $2,254.55
| Professional | | $541.09 | $2,254.55 | $2,254.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $541.09 / $824.60 / $1,009.10
| Facility | | $541.09 | $824.60 | $1,009.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.09 / $982.61 / $1,154.33
| Professional | | $541.09 | $982.61 | $1,154.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.55 / $527.55 / $919.86
| Professional | | $527.55 | $527.55 | $919.86 |