- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.71 / $1,162.71 / $1,162.71
| Professional | | $1,162.71 | $1,162.71 | $1,162.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.53 / $2,506.53 / $2,506.53
| Facility | | $2,506.53 | $2,506.53 | $2,506.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.71 / $163.71 / $2,202.34
| Professional | | $163.71 | $163.71 | $2,202.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.78 / $3,673.20 / $3,846.28
| Professional | | $248.78 | $3,673.20 | $3,846.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $286.64 / $286.64
| Professional | | $286.64 | $286.64 | $286.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.68 / $1,847.79 / $2,506.53
| Professional | | $981.68 | $1,847.79 | $2,506.53 |