- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.69 / $2,496.69 / $11,840.10
| Professional | | $2,496.69 | $2,496.69 | $11,840.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,729.50
| Professional | | $2,271.73 | $2,672.64 | $4,729.50 |
- 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
- $1,404.39 / $2,047.28 / $3,120.86
| Professional | | $1,404.39 | $2,047.28 | $3,120.86 |