- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $2,550.00 / $2,550.00
| Professional | | $1,751.72 | $2,550.00 | $2,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.89 / $81.89 / $102.36
| Facility | | $81.89 | $81.89 | $102.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.82 / $2,129.09 / $3,539.61
| Professional | | $1,596.82 | $2,129.09 | $3,539.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $783.67
| Professional | | $783.67 | $783.67 | $783.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.36 / $1,751.72 / $2,550.00
| Facility | | $81.36 | $1,751.72 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.21 / $2,411.21 / $2,411.21
| Professional | | $2,411.21 | $2,411.21 | $2,411.21 |