- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,487.00 / $2,487.00 / $4,936.10
| Professional | | $2,487.00 | $2,487.00 | $4,936.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,829.20 / $4,829.20 / $4,829.20
| Professional | | $4,829.20 | $4,829.20 | $4,829.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Professional | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.56 / $2,022.10 / $2,326.23
| Professional | | $1,866.56 | $2,022.10 | $2,326.23 |