- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,877.34 / $10,371.78 / $14,312.52
| Professional | | $5,877.34 | $10,371.78 | $14,312.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.11 / $1,362.11 / $1,362.11
| Professional | | $1,362.11 | $1,362.11 | $1,362.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.72 / $11,155.72 / $11,155.72
| Facility | | $11,155.72 | $11,155.72 | $11,155.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.76 / $11,155.72 / $21,056.25
| Professional | | $1,347.76 | $11,155.72 | $21,056.25 |
- 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
- $817.28 / $2,724.21 / $8,322.12
| Professional | | $817.28 | $2,724.21 | $8,322.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,278.60 / $5,990.04 / $14,164.55
| Professional | | $4,278.60 | $5,990.04 | $14,164.55 |