- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.50 / $2,714.25 / $2,994.38
| Professional | | $2,395.50 | $2,714.25 | $2,994.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.32 / $317.25 / $3,503.42
| Facility | | $293.32 | $317.25 | $3,503.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.32 / $341.66 / $3,772.92
| Professional | | $293.32 | $341.66 | $3,772.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $5,189.56
| Facility | | $2,200.00 | $2,200.00 | $5,189.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $3,165.30
| Professional | | $354.66 | $2,200.00 | $3,165.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,989.62 / $2,707.56 / $4,255.87
| Professional | | $1,989.62 | $2,707.56 | $4,255.87 |