- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.50 / $1,663.50 / $1,663.50
| Professional | | $1,663.50 | $1,663.50 | $1,663.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.87 / $3,473.99 / $3,571.52
| Professional | | $2,739.87 | $3,473.99 | $3,571.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.16 / $1,663.50 / $1,663.50
| Facility | | $266.16 | $1,663.50 | $1,663.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.80 / $1,565.64 / $4,204.60
| Professional | | $1,330.80 | $1,565.64 | $4,204.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.00 / $1,565.64 / $3,843.65
| Professional | | $1,109.00 | $1,565.64 | $3,843.65 |