- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,805.95 / $2,805.95 / $5,551.30
| Professional | | $2,805.95 | $2,805.95 | $5,551.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,448.50 / $5,448.50 / $5,448.50
| Professional | | $5,448.50 | $5,448.50 | $5,448.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Facility | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,124.25 / $4,124.25 / $4,124.25
| Professional | | $4,124.25 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,095.94 / $2,274.09 / $3,725.20
| Professional | | $2,095.94 | $2,274.09 | $3,725.20 |