- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,588.75 / $4,588.75 / $8,036.20
| Professional | | $4,588.75 | $4,588.75 | $8,036.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,962.40 / $8,962.40 / $8,962.40
| Professional | | $8,962.40 | $8,962.40 | $8,962.40 |
- 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
- $3,087.00 / $3,087.00 / $3,790.53
| Professional | | $3,087.00 | $3,087.00 | $3,790.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.01 / $2,594.52 / $3,908.30
| Professional | | $2,199.01 | $2,594.52 | $3,908.30 |