- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.81 / $2,150.81 / $2,150.81
| Professional | | $2,150.81 | $2,150.81 | $2,150.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.42 / $915.42 / $2,010.52
| Facility | | $915.42 | $915.42 | $2,010.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.42 / $2,202.64 / $2,202.64
| Professional | | $915.42 | $2,202.64 | $2,202.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.42 / $915.42 / $2,010.52
| Facility | | $915.42 | $915.42 | $2,010.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.22 / $938.75 / $2,479.75
| Professional | | $610.22 | $938.75 | $2,479.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.44 / $2,159.44 / $2,159.44
| Professional | | $2,159.44 | $2,159.44 | $2,159.44 |