- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,578.75 / $3,578.75 / $6,267.00
| Professional | | $3,578.75 | $3,578.75 | $6,267.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,989.30 / $6,989.30 / $6,989.30
| Professional | | $6,989.30 | $6,989.30 | $6,989.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Professional | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.56 / $2,266.29 / $5,248.20
| Professional | | $1,968.56 | $2,266.29 | $5,248.20 |