- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,668.35 / $4,681.80 / $4,954.05
| Professional | | $2,668.35 | $4,681.80 | $4,954.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,770.00 / $4,770.00 / $4,770.00
| Professional | | $4,770.00 | $4,770.00 | $4,770.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,461.85 / $3,461.85 / $3,461.85
| Facility | | $3,461.85 | $3,461.85 | $3,461.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.13 / $3,461.85 / $7,357.50
| Professional | | $499.13 | $3,461.85 | $7,357.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.12 / $3,120.18 / $4,940.29
| Professional | | $2,080.12 | $3,120.18 | $4,940.29 |