- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,140.21 / $7,306.26 / $10,082.25
| Professional | | $4,140.21 | $7,306.26 | $10,082.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,343.04 / $5,109.46 / $18,539.06
| Professional | | $4,343.04 | $5,109.46 | $18,539.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $200.00
| Professional | | $100.00 | $100.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.72 / $1,919.03 / $5,862.53
| Professional | | $575.72 | $1,919.03 | $5,862.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.00 / $4,255.04 / $7,534.52
| Professional | | $3,014.00 | $4,255.04 | $7,534.52 |