- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,727.25 / $3,727.25 / $7,309.50
| Professional | | $3,727.25 | $3,727.25 | $7,309.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,237.40 / $7,237.40 / $7,237.40
| Professional | | $7,237.40 | $7,237.40 | $7,237.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Professional | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.48 / $2,960.16 / $4,822.60
| Professional | | $2,713.48 | $2,960.16 | $4,822.60 |