- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.13 / $1,015.13 / $1,268.91
| Professional | | $1,015.13 | $1,015.13 | $1,268.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.04 / $1,306.04 / $1,967.58
| Facility | | $1,306.04 | $1,306.04 | $1,967.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,008.06 / $6,008.06 / $6,008.06
| Professional | | $6,008.06 | $6,008.06 | $6,008.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.30 / $983.40 / $983.40
| Facility | | $141.30 | $983.40 | $983.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.09 / $141.30 / $983.40
| Professional | | $101.09 | $141.30 | $983.40 |