- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,988.53 / $3,522.53 / $20,833.20
| Professional | | $1,988.53 | $3,522.53 | $20,833.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,422.95 / $5,422.95 / $5,422.95
| Facility | | $5,422.95 | $5,422.95 | $5,422.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,280.01 / $7,280.01 / $7,280.01
| Professional | | $7,280.01 | $7,280.01 | $7,280.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,422.95 / $5,422.95 / $5,422.95
| Facility | | $5,422.95 | $5,422.95 | $5,422.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.00 / $1,170.00 / $7,280.01
| Professional | | $1,170.00 | $1,170.00 | $7,280.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.23 / $2,840.75 / $14,580.00
| Professional | | $1,415.23 | $2,840.75 | $14,580.00 |