- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.25 / $1,202.25 / $1,202.25
| Professional | | $1,202.25 | $1,202.25 | $1,202.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,749.00 / $3,100.00 / $3,720.00
| Professional | | $2,749.00 | $3,100.00 | $3,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.33 / $1,822.46 / $2,983.62
| Professional | | $1,798.33 | $1,822.46 | $2,983.62 |
- 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
- $1,563.68 / $3,953.77 / $5,196.84
| Professional | | $1,563.68 | $3,953.77 | $5,196.84 |