- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.69 / $1,069.69 / $1,337.11
| Professional | | $1,069.69 | $1,069.69 | $1,337.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.51 / $1,008.00 / $1,548.10
| Facility | | $680.51 | $1,008.00 | $1,548.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.19 / $1,096.93 / $2,567.06
| Professional | | $608.19 | $1,096.93 | $2,567.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.00 / $1,008.00 / $1,008.00
| Facility | | $1,008.00 | $1,008.00 | $1,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.19 / $958.96 / $1,103.65
| Professional | | $608.19 | $958.96 | $1,103.65 |