- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.21 / $2,093.98 / $2,443.50
| Professional | | $1,702.21 | $2,093.98 | $2,443.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.83 / $330.83 / $330.83
| Facility | | $330.83 | $330.83 | $330.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.96 / $244.96 / $244.96
| Professional | | $244.96 | $244.96 | $244.96 |
- 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 / $2,160.00
| Professional | | $259.39 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.76 / $1,226.89 / $3,145.04
| Professional | | $979.76 | $1,226.89 | $3,145.04 |