- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.86 / $871.86 / $1,006.00
| Professional | | $871.86 | $871.86 | $1,006.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,022.07
| Facility | | $1,022.07 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $1,052.73
| Professional | | $868.76 | $1,022.07 | $1,052.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,022.07
| Facility | | $1,022.07 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $1,052.73
| Professional | | $868.76 | $1,022.07 | $1,052.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.23 / $1,229.49 / $2,063.38
| Professional | | $594.23 | $1,229.49 | $2,063.38 |