- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.40 / $1,665.40 / $3,466.20
| Professional | | $1,665.40 | $1,665.40 | $3,466.20 |
- 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
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $3,373.90
| Professional | | $2,592.00 | $2,592.00 | $3,373.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.72 / $1,526.70 / $2,544.50
| Professional | | $1,277.72 | $1,526.70 | $2,544.50 |