- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.83 / $1,579.83 / $1,579.83
| Professional | | $1,579.83 | $1,579.83 | $1,579.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.73 / $1,070.84 / $1,330.52
| Professional | | $799.73 | $1,070.84 | $1,330.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $3,936.44 / $5,422.93
| Facility | | $3,873.00 | $3,936.44 | $5,422.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.92 / $2,201.19 / $2,201.19
| Professional | | $1,019.92 | $2,201.19 | $2,201.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.73 / $1,808.63 / $3,086.05
| Professional | | $642.73 | $1,808.63 | $3,086.05 |