- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.16 / $2,254.63 / $2,399.42
| Professional | | $2,089.16 | $2,254.63 | $2,399.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.97 / $200.97 / $2,068.46
| Facility | | $200.97 | $200.97 | $2,068.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.00 / $2,068.46 / $2,068.46
| Professional | | $191.00 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $3,462.50
| Facility | | $2,068.46 | $2,068.46 | $3,462.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,244.10 / $3,324.00
| Professional | | $2,068.46 | $2,244.10 | $3,324.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |