- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.67 / $1,844.67 / $1,844.67
| Professional | | $1,844.67 | $1,844.67 | $1,844.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,301.52 / $1,301.52 / $1,666.87
| Facility | | $1,301.52 | $1,301.52 | $1,666.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,061.69 / $2,170.19 / $5,014.03
| Professional | | $2,061.69 | $2,170.19 | $5,014.03 |