- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,386.40 / $3,386.40 / $3,725.04
| Professional | | $3,386.40 | $3,386.40 | $3,725.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $3,468.00
| Facility | | $3,468.00 | $3,468.00 | $3,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,468.00 / $3,468.00 / $5,232.60
| Professional | | $3,468.00 | $3,468.00 | $5,232.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.60 / $4,651.20 / $5,426.40
| Professional | | $4,263.60 | $4,651.20 | $5,426.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.40 / $5,100.00 / $5,232.60
| Professional | | $2,145.40 | $5,100.00 | $5,232.60 |