- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.75 / $1,098.75 / $1,098.75
| Professional | | $1,098.75 | $1,098.75 | $1,098.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,144.00 / $2,573.00 / $3,216.00
| Professional | | $2,144.00 | $2,573.00 | $3,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.13 / $1,837.90 / $2,580.59
| Professional | | $1,494.13 | $1,837.90 | $2,580.59 |
- 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
- $1,788.05 / $2,919.94 / $4,771.80
| Professional | | $1,788.05 | $2,919.94 | $4,771.80 |