- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.17 / $2,554.17 / $2,554.17
| Professional | | $2,554.17 | $2,554.17 | $2,554.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.43 / $1,335.43 / $1,335.43
| Facility | | $1,335.43 | $1,335.43 | $1,335.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,597.18 / $5,597.18 / $5,597.18
| Professional | | $5,597.18 | $5,597.18 | $5,597.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,576.10 / $3,576.10 / $3,576.10
| Facility | | $3,576.10 | $3,576.10 | $3,576.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.45 / $1,122.41 / $2,323.39
| Professional | | $673.45 | $1,122.41 | $2,323.39 |