- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,253.09 / $7,505.46 / $10,357.11
| Professional | | $4,253.09 | $7,505.46 | $10,357.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,072.81 / $8,072.81 / $8,072.81
| Facility | | $8,072.81 | $8,072.81 | $8,072.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.29 / $8,072.81 / $15,236.25
| Professional | | $975.29 | $8,072.81 | $15,236.25 |
- 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
- $591.41 / $1,971.35 / $6,022.23
| Professional | | $591.41 | $1,971.35 | $6,022.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,096.17 / $4,371.04 / $7,503.62
| Professional | | $3,096.17 | $4,371.04 | $7,503.62 |