- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.53 / $2,028.53 / $2,028.53
| Professional | | $2,028.53 | $2,028.53 | $2,028.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,299.95 / $3,299.95 / $4,577.53
| Facility | | $3,299.95 | $3,299.95 | $4,577.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,300.00 / $1,300.00
| Professional | | $1,300.00 | $1,300.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.68 / $1,562.34 / $2,393.67
| Professional | | $1,014.68 | $1,562.34 | $2,393.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |