- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.20 / $1,173.20 / $1,173.20
| Professional | | $1,173.20 | $1,173.20 | $1,173.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.00 / $2,741.00 / $3,425.00
| Professional | | $2,284.00 | $2,741.00 | $3,425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.72 / $1,923.99 / $2,412.15
| Professional | | $1,403.72 | $1,923.99 | $2,412.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.35 / $2,618.73 / $4,039.20
| Professional | | $1,626.35 | $2,618.73 | $4,039.20 |