- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.03 / $5,054.00 / $5,054.00
| Professional | | $1,201.03 | $5,054.00 | $5,054.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,540.07 / $1,540.07 / $1,540.07
| Facility | | $1,540.07 | $1,540.07 | $1,540.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.83 / $939.78 / $1,540.07
| Professional | | $927.83 | $939.78 | $1,540.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.86 / $1,126.08 / $1,540.07
| Facility | | $909.86 | $1,126.08 | $1,540.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.83 / $1,318.53 / $1,828.55
| Professional | | $927.83 | $1,318.53 | $1,828.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.00 / $1,450.00 / $1,450.00
| Facility | | $1,450.00 | $1,450.00 | $1,450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.08 / $1,566.58 / $1,890.70
| Professional | | $1,397.08 | $1,566.58 | $1,890.70 |