- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.30 / $2,256.30 / $3,992.50
| Professional | | $2,256.30 | $2,256.30 | $3,992.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,381.10 / $4,381.10 / $4,381.10
| Professional | | $4,381.10 | $4,381.10 | $4,381.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $4,532.07
| Facility | | $2,200.00 | $2,200.00 | $4,532.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Professional | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.33 / $2,263.38 / $2,767.87
| Professional | | $2,035.33 | $2,263.38 | $2,767.87 |