- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.40 / $1,665.40 / $3,489.80
| Professional | | $1,665.40 | $1,665.40 | $3,489.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,233.70 / $3,233.70 / $3,233.70
| Professional | | $3,233.70 | $3,233.70 | $3,233.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,254.90
| Facility | | $2,254.90 | $2,254.90 | $2,254.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $3,230.73
| Professional | | $2,254.90 | $2,254.90 | $3,230.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.80 / $1,554.24 / $2,296.26
| Professional | | $1,285.80 | $1,554.24 | $2,296.26 |