- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.40 / $1,588.40 / $3,012.40
| Professional | | $1,588.40 | $1,588.40 | $3,012.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,084.30 / $3,084.30 / $3,084.30
| Professional | | $3,084.30 | $3,084.30 | $3,084.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Professional | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.08 / $1,139.00 / $1,855.70
| Professional | | $1,044.08 | $1,139.00 | $1,855.70 |