- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,922.40 / $2,922.40 / $5,843.40
| Professional | | $2,922.40 | $2,922.40 | $5,843.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,674.60 / $5,674.60 / $5,674.60
| Professional | | $5,674.60 | $5,674.60 | $5,674.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Professional | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.71 / $2,399.88 / $3,999.80
| Professional | | $2,209.71 | $2,399.88 | $3,999.80 |