- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.27 / $1,205.27 / $1,506.59
| Professional | | $1,205.27 | $1,205.27 | $1,506.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.88 / $1,707.88 / $1,707.88
| Facility | | $1,707.88 | $1,707.88 | $1,707.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.00 / $3,641.06 / $3,641.06
| Professional | | $654.00 | $3,641.06 | $3,641.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.00 / $765.49 / $961.45
| Facility | | $654.00 | $765.49 | $961.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.00 / $961.45 / $1,520.57
| Professional | | $221.00 | $961.45 | $1,520.57 |