- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.67 / $1,302.67 / $1,503.08
| Professional | | $1,302.67 | $1,302.67 | $1,503.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $1,962.03
| Facility | | $1,304.10 | $1,304.10 | $1,962.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,246.79 / $1,343.23
| Professional | | $952.00 | $1,246.79 | $1,343.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $1,962.03
| Facility | | $1,304.10 | $1,304.10 | $1,962.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,304.10 / $1,343.23
| Professional | | $952.00 | $1,304.10 | $1,343.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.84 / $1,581.31 / $3,086.03
| Professional | | $887.84 | $1,581.31 | $3,086.03 |