- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,206.00 / $4,007.50 / $6,711.29
| Professional | | $3,206.00 | $4,007.50 | $6,711.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,661.36 / $5,661.36 / $5,661.36
| Facility | | $5,661.36 | $5,661.36 | $5,661.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,476.00 / $7,378.98 / $7,378.98
| Professional | | $2,476.00 | $7,378.98 | $7,378.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,759.79 / $2,280.67 / $2,690.05
| Facility | | $1,759.79 | $2,280.67 | $2,690.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.00 / $2,690.05 / $3,104.38
| Professional | | $1,981.00 | $2,690.05 | $3,104.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $1,671.70 / $4,008.80
| Professional | | $15.00 | $1,671.70 | $4,008.80 |