- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.87 / $1,982.30 / $2,605.23
| Professional | | $1,389.87 | $1,982.30 | $2,605.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,616.48 / $2,616.48 / $2,616.48
| Professional | | $2,616.48 | $2,616.48 | $2,616.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.64 / $1,440.00 / $3,832.50
| Professional | | $233.64 | $1,440.00 | $3,832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.50 / $1,388.47 / $2,202.82
| Professional | | $927.50 | $1,388.47 | $2,202.82 |