- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,461.75 / $2,461.75 / $4,898.10
| Professional | | $2,461.75 | $2,461.75 | $4,898.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,780.10 / $4,780.10 / $4,780.10
| Professional | | $4,780.10 | $4,780.10 | $4,780.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Professional | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.20 / $2,006.55 / $3,322.10
| Professional | | $1,852.20 | $2,006.55 | $3,322.10 |