- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,948.48 / $3,948.48 / $4,935.60
| Professional | | $3,948.48 | $3,948.48 | $4,935.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,575.05 / $2,852.51 / $6,919.50
| Facility | | $2,575.05 | $2,852.51 | $6,919.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,487.00 / $8,793.54 / $8,793.54
| Professional | | $3,487.00 | $8,793.54 | $8,793.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,487.00 / $3,487.00 / $3,487.00
| Facility | | $3,487.00 | $3,487.00 | $3,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.00 / $3,528.28 / $3,775.36
| Professional | | $2,527.00 | $3,528.28 | $3,775.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $2,730.20 / $3,866.00
| Professional | | $11.00 | $2,730.20 | $3,866.00 |