- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.88 / $1,222.88 / $1,222.88
| Professional | | $1,222.88 | $1,222.88 | $1,222.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.00 / $2,863.00 / $3,580.00
| Professional | | $2,386.00 | $2,863.00 | $3,580.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.27 / $2,045.86 / $2,870.32
| Professional | | $1,656.27 | $2,045.86 | $2,870.32 |
- 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
- $1,926.65 / $3,081.78 / $4,771.80
| Professional | | $1,926.65 | $3,081.78 | $4,771.80 |