- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,887.00 / $3,887.00 / $6,775.60
| Professional | | $3,887.00 | $3,887.00 | $6,775.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,591.80 / $7,591.80 / $7,591.80
| Professional | | $7,591.80 | $7,591.80 | $7,591.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $7,531.79
| Facility | | $4,775.22 | $4,775.22 | $7,531.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,775.22 / $4,775.22 / $4,775.22
| Professional | | $4,775.22 | $4,775.22 | $4,775.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,241.76 / $3,831.17 / $4,579.33
| Professional | | $3,241.76 | $3,831.17 | $4,579.33 |