- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.90 / $2,041.73 / $2,220.44
| Professional | | $1,761.90 | $2,041.73 | $2,220.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.77 / $270.49 / $2,302.83
| Facility | | $219.77 | $270.49 | $2,302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.77 / $244.44 / $2,479.96
| Professional | | $219.77 | $244.44 | $2,479.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $3,300.57
| Facility | | $2,160.00 | $2,160.00 | $3,300.57 |
- 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
- $1,259.48 / $1,481.07 / $2,623.28
| Professional | | $1,259.48 | $1,481.07 | $2,623.28 |