- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.76 / $3,299.58 / $4,644.32
| Professional | | $1,869.76 | $3,299.58 | $4,644.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.41 / $435.41 / $435.41
| Professional | | $435.41 | $435.41 | $435.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $5,616.25
| Facility | | $3,282.89 | $3,282.89 | $5,616.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.23 / $3,282.89 / $6,731.25
| Professional | | $498.23 | $3,282.89 | $6,731.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $852.08
| Professional | | $100.00 | $200.00 | $852.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.12 / $870.81 / $4,675.99
| Professional | | $653.12 | $870.81 | $4,675.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.10 / $3,036.32 / $5,271.81
| Professional | | $2,390.10 | $3,036.32 | $5,271.81 |