- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,293.88 / $2,293.88 / $2,293.88
| Professional | | $2,293.88 | $2,293.88 | $2,293.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,288.68 / $7,288.68 / $7,288.68
| Facility | | $7,288.68 | $7,288.68 | $7,288.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,237.00 / $3,237.00 / $3,970.63
| Professional | | $3,237.00 | $3,237.00 | $3,970.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,237.00 / $3,237.00 / $3,237.00
| Facility | | $3,237.00 | $3,237.00 | $3,237.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.28 / $3,237.00 / $4,289.31
| Professional | | $2,453.28 | $3,237.00 | $4,289.31 |