- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.80 / $2,746.80 / $2,746.80
| Professional | | $2,746.80 | $2,746.80 | $2,746.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $2,183.76 / $6,060.94
| Professional | | $295.60 | $2,183.76 | $6,060.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.99 / $177.36 / $273.31
| Professional | | $163.99 | $177.36 | $273.31 |