- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.92 / $4,323.34 / $5,474.70
| Professional | | $2,127.92 | $4,323.34 | $5,474.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $4,222.77
| Facility | | $55.00 | $55.00 | $4,222.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,494.34 / $5,494.34 / $5,494.34
| Professional | | $5,494.34 | $5,494.34 | $5,494.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,111.53 / $1,399.91 / $2,083.94
| Facility | | $1,111.53 | $1,399.91 | $2,083.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,277.09 / $2,447.40
| Professional | | $7.00 | $1,277.09 | $2,447.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.16 / $1,403.22 / $2,163.67
| Facility | | $1,127.16 | $1,403.22 | $2,163.67 |