- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $501.19 / $2,884.03
| Facility | | $151.36 | $501.19 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $3,311.31
| Professional | | $891.25 | $1,548.82 | $3,311.31 |