- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.10 / $1,031.10 / $1,031.10
| Professional | | $1,031.10 | $1,031.10 | $1,031.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.00 / $2,414.00 / $3,019.00
| Professional | | $2,012.00 | $2,414.00 | $3,019.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.01 / $1,725.21 / $2,416.27
| Professional | | $1,400.01 | $1,725.21 | $2,416.27 |
- 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
- $1,632.95 / $2,612.01 / $4,036.56
| Professional | | $1,632.95 | $2,612.01 | $4,036.56 |