- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.01 / $4,887.08 / $4,887.08
| Professional | | $1,409.01 | $4,887.08 | $4,887.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $2,247.50 / $2,247.50
| Facility | | $1,018.60 | $2,247.50 | $2,247.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.60 / $2,247.50 / $2,247.50
| Professional | | $1,018.60 | $2,247.50 | $2,247.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.83 / $2,140.48 / $2,247.50
| Facility | | $908.83 | $2,140.48 | $2,247.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.57 / $1,686.85 / $2,249.14
| Professional | | $1,551.57 | $1,686.85 | $2,249.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.02 / $813.25 / $1,289.81
| Professional | | $735.02 | $813.25 | $1,289.81 |