- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.88 / $3,454.88 / $3,454.88
| Professional | | $3,454.88 | $3,454.88 | $3,454.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,087.00 / $3,087.00
| Facility | | $3,087.00 | $3,087.00 | $3,087.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.63 / $3,087.00 / $10,638.75
| Professional | | $648.63 | $3,087.00 | $10,638.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,076.94 / $3,662.56 / $5,806.50
| Professional | | $2,076.94 | $3,662.56 | $5,806.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.44 / $2,594.52 / $4,972.10
| Professional | | $2,237.44 | $2,594.52 | $4,972.10 |