- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.50 / $1,189.50 / $1,189.50
| Professional | | $1,189.50 | $1,189.50 | $1,189.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.00 / $2,616.00 / $3,817.00
| Professional | | $2,180.00 | $2,616.00 | $3,817.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.39 / $2,016.98 / $2,750.82
| Professional | | $1,589.39 | $2,016.98 | $2,750.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.65 / $2,656.00 / $4,691.29
| Professional | | $1,783.65 | $2,656.00 | $4,691.29 |