- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.46 / $1,063.46 / $4,969.49
| Professional | | $1,063.46 | $1,063.46 | $4,969.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,116.58
| Facility | | $1,116.58 | $1,116.58 | $1,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,974.00
| Professional | | $949.10 | $1,116.58 | $1,974.00 |
- 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
- $598.19 / $859.28 / $1,329.32
| Professional | | $598.19 | $859.28 | $1,329.32 |