- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.00 / $1,201.00 / $1,201.00
| Professional | | $1,201.00 | $1,201.00 | $1,201.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.00 / $1,218.00 / $2,266.00
| Facility | | $606.00 | $1,218.00 | $2,266.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.08 / $362.47 / $362.47
| Professional | | $308.08 | $362.47 | $362.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.00 / $2,031.53 / $2,242.96
| Facility | | $467.00 | $2,031.53 | $2,242.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.63 / $2,376.25 / $4,514.88
| Facility | | $2,138.63 | $2,376.25 | $4,514.88 |