- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.15 / $2,333.67 / $2,624.49
| Professional | | $1,468.15 | $2,333.67 | $2,624.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,500.00 / $2,500.00
| Professional | | $2,500.00 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Facility | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.39 / $2,160.00 / $4,050.00
| Professional | | $259.39 | $2,160.00 | $4,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.76 / $1,306.51 / $2,152.23
| Professional | | $979.76 | $1,306.51 | $2,152.23 |