- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,269.05 / $2,269.05 / $4,604.50
| Professional | | $2,269.05 | $2,269.05 | $4,604.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,406.00 / $4,406.00 / $4,406.00
| Professional | | $4,406.00 | $4,406.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Professional | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.32 / $1,941.96 / $3,236.60
| Professional | | $1,741.32 | $1,941.96 | $3,236.60 |