- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.41 / $1,895.41 / $1,895.41
| Professional | | $1,895.41 | $1,895.41 | $1,895.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $6,918.75
| Professional | | $470.42 | $1,642.21 | $6,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.67 / $3,572.14 / $5,663.16
| Professional | | $2,025.67 | $3,572.14 | $5,663.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.41 / $2,938.92 / $4,615.85
| Professional | | $1,895.41 | $2,938.92 | $4,615.85 |