- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.96 / $2,403.96 / $3,004.95
| Professional | | $2,403.96 | $2,403.96 | $3,004.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $11,632.60
| Facility | | $55.00 | $55.00 | $11,632.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,543.26 / $8,064.84 / $8,064.84
| Professional | | $6,543.26 | $8,064.84 | $8,064.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.13 / $1,715.39 / $3,286.00
| Facility | | $1,351.13 | $1,715.39 | $3,286.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.30 / $1,778.30 / $1,778.30
| Professional | | $1,778.30 | $1,778.30 | $1,778.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.13 / $1,787.76 / $3,286.00
| Facility | | $1,351.13 | $1,787.76 | $3,286.00 |