- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,247.49 / $3,247.49 / $4,059.36
| Professional | | $3,247.49 | $3,247.49 | $4,059.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $6,598.41
| Facility | | $55.00 | $55.00 | $6,598.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,426.08 / $8,426.08 / $8,426.08
| Professional | | $8,426.08 | $8,426.08 | $8,426.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,986.73 / $2,499.78 / $3,795.00
| Facility | | $1,986.73 | $2,499.78 | $3,795.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,323.19 / $2,323.19 / $2,323.19
| Professional | | $2,323.19 | $2,323.19 | $2,323.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,986.73 / $2,499.78 / $3,795.00
| Facility | | $1,986.73 | $2,499.78 | $3,795.00 |