- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.90 / $2,345.13 / $2,426.94
| Professional | | $1,761.90 | $2,345.13 | $2,426.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.28 / $2,135.09 / $2,135.09
| Professional | | $1,964.28 | $2,135.09 | $2,135.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $3,287.59
| Facility | | $2,160.00 | $2,160.00 | $3,287.59 |
- 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 / $1,299.61 / $2,124.11
| Professional | | $979.76 | $1,299.61 | $2,124.11 |