- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,113.64 / $4,113.64 / $5,142.06
| Professional | | $4,113.64 | $4,113.64 | $5,142.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,604.80 / $11,604.80 / $11,604.80
| Facility | | $11,604.80 | $11,604.80 | $11,604.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,198.00 / $9,782.46 / $9,782.46
| Professional | | $3,198.00 | $9,782.46 | $9,782.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,198.00 / $3,198.00 / $3,198.00
| Facility | | $3,198.00 | $3,198.00 | $3,198.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.00 / $3,720.88 / $3,811.95
| Professional | | $2,886.00 | $3,720.88 | $3,811.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $2,471.50 / $4,215.80
| Professional | | $6.00 | $2,471.50 | $4,215.80 |