- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,726.44 / $3,726.44 / $4,658.04
| Professional | | $3,726.44 | $3,726.44 | $4,658.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $3,506.00 / $6,773.97
| Facility | | $55.00 | $3,506.00 | $6,773.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,711.00 / $3,506.00 / $12,919.80
| Professional | | $2,711.00 | $3,506.00 | $12,919.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,945.64 / $2,521.55 / $3,506.00
| Facility | | $1,945.64 | $2,521.55 | $3,506.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.94 / $3,037.00 / $3,506.00
| Professional | | $1,844.94 | $3,037.00 | $3,506.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,017.60 / $3,282.50 / $3,955.40
| Professional | | $3,017.60 | $3,282.50 | $3,955.40 |