- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.20 / $1,084.20 / $1,084.20
| Professional | | $1,084.20 | $1,084.20 | $1,084.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.00 / $2,540.00 / $3,175.00
| Professional | | $2,117.00 | $2,540.00 | $3,175.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.68 / $1,814.33 / $2,754.61
| Professional | | $1,488.68 | $1,814.33 | $2,754.61 |
- 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
- $1,669.25 / $2,428.64 / $4,193.62
| Professional | | $1,669.25 | $2,428.64 | $4,193.62 |