- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,255.38 / $7,304.16 / $10,054.79
| Professional | | $5,255.38 | $7,304.16 | $10,054.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,391.94 / $8,391.94 / $8,391.94
| Facility | | $8,391.94 | $8,391.94 | $8,391.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,133.15 / $8,391.94 / $16,584.38
| Professional | | $7,133.15 | $8,391.94 | $16,584.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $1,430.10
| Professional | | $100.00 | $200.00 | $1,430.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.03 / $1,716.77 / $7,862.07
| Professional | | $515.03 | $1,716.77 | $7,862.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,568.08 / $5,157.60 / $8,800.59
| Professional | | $3,568.08 | $5,157.60 | $8,800.59 |