- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.40 / $1,238.40 / $1,238.40
| Professional | | $1,238.40 | $1,238.40 | $1,238.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.00 / $2,894.00 / $3,618.00
| Professional | | $2,412.00 | $2,894.00 | $3,618.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.65 / $2,031.28 / $2,853.08
| Professional | | $1,604.65 | $2,031.28 | $2,853.08 |
- 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
- $1,796.85 / $2,952.31 / $4,742.76
| Professional | | $1,796.85 | $2,952.31 | $4,742.76 |