- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.37 / $2,460.37 / $2,460.37
| Professional | | $2,460.37 | $2,460.37 | $2,460.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $5,753.88
| Facility | | $55.00 | $55.00 | $5,753.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,341.00 / $15,341.00 / $15,341.00
| Professional | | $15,341.00 | $15,341.00 | $15,341.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.86 / $2,211.71 / $3,634.56
| Facility | | $1,669.86 | $2,211.71 | $3,634.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,609.90 / $2,609.90 / $2,609.90
| Professional | | $2,609.90 | $2,609.90 | $2,609.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.86 / $2,211.71 / $3,634.56
| Facility | | $1,669.86 | $2,211.71 | $3,634.56 |