- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.40 / $1,482.01 / $1,482.01
| Professional | | $933.40 | $1,482.01 | $1,482.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.40 / $2,100.40 / $2,100.40
| Professional | | $2,100.40 | $2,100.40 | $2,100.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.56 / $1,350.00 / $1,525.76
| Professional | | $209.56 | $1,350.00 | $1,525.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.81 / $5,981.40 / $7,581.21
| Professional | | $2,130.81 | $5,981.40 | $7,581.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,346.88 / $2,130.81
| Professional | | $889.04 | $1,346.88 | $2,130.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.98 / $2,355.54 / $2,997.96
| Professional | | $2,125.98 | $2,355.54 | $2,997.96 |