- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.49 / $2,090.59 / $2,090.59
| Professional | | $244.49 | $2,090.59 | $2,090.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,027.84 / $2,230.62 / $2,570.80
| Professional | | $2,027.84 | $2,230.62 | $2,570.80 |
- 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 / $2,904.98
| Professional | | $259.39 | $2,160.00 | $2,904.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.49 / $1,468.15 / $2,090.59
| Professional | | $244.49 | $1,468.15 | $2,090.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.72 / $1,469.15 / $3,773.28
| Professional | | $981.72 | $1,469.15 | $3,773.28 |