- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,205.95 / $3,205.95 / $4,007.44
| Professional | | $3,205.95 | $3,205.95 | $4,007.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $6,604.80
| Facility | | $55.00 | $55.00 | $6,604.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,314.60 / $8,314.60 / $8,314.60
| Professional | | $8,314.60 | $8,314.60 | $8,314.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.19 / $2,511.06 / $3,586.42
| Facility | | $2,005.19 | $2,511.06 | $3,586.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.40 / $2,334.40 / $2,334.40
| Professional | | $2,334.40 | $2,334.40 | $2,334.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.19 / $2,511.06 / $3,586.42
| Facility | | $2,005.19 | $2,511.06 | $3,586.42 |