- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,398.25 / $3,398.25 / $5,951.20
| Professional | | $3,398.25 | $3,398.25 | $5,951.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,637.20 / $6,637.20 / $6,637.20
| Professional | | $6,637.20 | $6,637.20 | $6,637.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $5,596.94
| Facility | | $2,900.00 | $2,900.00 | $5,596.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,900.00
| Professional | | $2,900.00 | $2,900.00 | $2,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.59 / $2,860.46 / $4,341.33
| Professional | | $2,442.59 | $2,860.46 | $4,341.33 |