- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.65 / $3,484.84 / $7,172.61
| Professional | | $1,507.65 | $3,484.84 | $7,172.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $6,347.80
| Facility | | $55.00 | $55.00 | $6,347.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,467.74 / $9,467.74 / $11,001.20
| Professional | | $9,467.74 | $9,467.74 | $11,001.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $1,997.90 / $3,853.10
| Professional | | $7.00 | $1,997.90 | $3,853.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,909.50 / $3,909.50 / $3,909.50
| Facility | | $3,909.50 | $3,909.50 | $3,909.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.53 / $3,508.08 / $4,336.75
| Professional | | $1,806.53 | $3,508.08 | $4,336.75 |