- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,776.30 / $3,776.30 / $4,720.37
| Professional | | $3,776.30 | $3,776.30 | $4,720.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,383.37 / $2,718.26 / $6,598.41
| Facility | | $2,383.37 | $2,718.26 | $6,598.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,307.00 / $8,426.08 / $8,426.08
| Professional | | $3,307.00 | $8,426.08 | $8,426.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,307.00 / $3,307.00 / $3,307.00
| Facility | | $3,307.00 | $3,307.00 | $3,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.00 / $3,345.46 / $3,613.46
| Professional | | $2,534.00 | $3,345.46 | $3,613.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $2,525.10 / $3,660.00
| Professional | | $11.00 | $2,525.10 | $3,660.00 |