- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.59 / $1,001.59 / $1,001.59
| Professional | | $1,001.59 | $1,001.59 | $1,001.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.00 / $2,592.00 / $3,110.00
| Professional | | $2,298.00 | $2,592.00 | $3,110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.55 / $1,400.80 / $2,349.73
| Professional | | $1,372.55 | $1,400.80 | $2,349.73 |
- 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
- $1,165.30 / $3,073.40 / $4,004.88
| Professional | | $1,165.30 | $3,073.40 | $4,004.88 |