- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.69 / $2,187.69 / $4,439.60
| Professional | | $2,187.69 | $2,187.69 | $4,439.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,247.89 / $4,247.89 / $4,247.89
| Professional | | $4,247.89 | $4,247.89 | $4,247.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,931.29
| Professional | | $2,673.00 | $2,673.00 | $3,931.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,678.96 / $1,872.66 / $3,121.10
| Professional | | $1,678.96 | $1,872.66 | $3,121.10 |