- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.38 / $858.38 / $1,503.25
| Professional | | $858.38 | $858.38 | $1,503.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,676.51 / $1,676.51 / $1,676.51
| Facility | | $1,676.51 | $1,676.51 | $1,676.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.51 / $1,676.51 / $1,676.51
| Professional | | $1,676.51 | $1,676.51 | $1,676.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.53 / $1,473.53 / $2,517.90
| Facility | | $1,473.53 | $1,473.53 | $2,517.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.68 / $1,075.68 / $1,473.53
| Professional | | $1,075.68 | $1,075.68 | $1,473.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.09 / $856.46 / $1,319.79
| Professional | | $774.09 | $856.46 | $1,319.79 |