- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.31 / $2,388.60 / $3,296.16
| Professional | | $2,030.31 | $2,388.60 | $3,296.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.69 / $313.69 / $376.43
| Professional | | $313.69 | $313.69 | $376.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,183.76 / $2,569.13 / $6,060.94
| Professional | | $2,183.76 | $2,569.13 | $6,060.94 |
- 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
- $470.54 / $627.38 / $2,940.87
| Professional | | $470.54 | $627.38 | $2,940.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.36 / $200.63 / $369.49
| Professional | | $177.36 | $200.63 | $369.49 |