- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.38 / $1,008.38 / $1,008.38
| Professional | | $1,008.38 | $1,008.38 | $1,008.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,304.00 / $2,598.00 / $3,118.00
| Professional | | $2,304.00 | $2,598.00 | $3,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.05 / $1,549.43 / $2,596.98
| Professional | | $1,540.05 | $1,549.43 | $2,596.98 |
- 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
- $1,328.73 / $3,319.42 / $4,403.50
| Professional | | $1,328.73 | $3,319.42 | $4,403.50 |