- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.76 / $3,881.40 / $5,356.08
| Professional | | $2,081.76 | $3,881.40 | $5,356.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.74 / $564.11 / $564.11
| Professional | | $509.74 | $564.11 | $564.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $5,621.46
| Facility | | $2,900.00 | $2,900.00 | $5,621.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,900.00 / $7,878.75
| Professional | | $2,465.00 | $2,900.00 | $7,878.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $851.25
| Professional | | $100.00 | $200.00 | $851.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.61 / $1,019.48 / $4,671.37
| Professional | | $764.61 | $1,019.48 | $4,671.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,383.71 / $2,972.02 / $5,101.97
| Professional | | $2,383.71 | $2,972.02 | $5,101.97 |