- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.64 / $1,059.64 / $1,059.64
| Professional | | $1,059.64 | $1,059.64 | $1,059.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.55 / $1,612.00 / $3,329.00
| Professional | | $1,324.55 | $1,612.00 | $3,329.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,080.33 / $2,080.33 / $2,080.33
| Facility | | $2,080.33 | $2,080.33 | $2,080.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.08 / $1,302.19 / $1,627.74
| Professional | | $530.08 | $1,302.19 | $1,627.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.17 / $423.23 / $1,779.04
| Professional | | $415.17 | $423.23 | $1,779.04 |