- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.04 / $898.04 / $1,036.20
| Professional | | $898.04 | $898.04 | $1,036.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,352.58
| Facility | | $1,018.60 | $1,018.60 | $1,352.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $1,015.21
| Professional | | $743.58 | $743.58 | $1,015.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,352.58
| Facility | | $1,018.60 | $1,018.60 | $1,352.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $1,015.21
| Professional | | $743.58 | $743.58 | $1,015.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.07 / $1,225.32 / $2,127.44
| Professional | | $612.07 | $1,225.32 | $2,127.44 |