- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,395.56 / $3,395.56 / $4,244.45
| Professional | | $3,395.56 | $3,395.56 | $4,244.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $6,919.50
| Facility | | $55.00 | $55.00 | $6,919.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,793.54 / $8,793.54 / $8,793.54
| Professional | | $8,793.54 | $8,793.54 | $8,793.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,013.42 / $2,615.61 / $3,783.13
| Facility | | $2,013.42 | $2,615.61 | $3,783.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,580.60 / $2,580.60 / $2,580.60
| Professional | | $2,580.60 | $2,580.60 | $2,580.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,013.42 / $2,615.61 / $3,783.13
| Facility | | $2,013.42 | $2,615.61 | $3,783.13 |