- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.65 / $2,673.65 / $4,682.30
| Professional | | $2,673.65 | $2,673.65 | $4,682.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,222.00 / $5,222.00 / $5,222.00
| Facility | | $5,222.00 | $5,222.00 | $5,222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,222.00 / $5,222.00 / $5,222.00
| Professional | | $5,222.00 | $5,222.00 | $5,222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $248.35 / $248.35
| Professional | | $248.35 | $248.35 | $248.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.94 / $226.76 / $2,456.55
| Professional | | $204.94 | $226.76 | $2,456.55 |