- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.53 / $1,539.18 / $2,124.00
| Professional | | $825.53 | $1,539.18 | $2,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.14 / $242.57 / $242.57
| Professional | | $202.14 | $242.57 | $242.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $2,229.14
| Facility | | $1,208.78 | $1,208.78 | $2,229.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.01 / $1,208.78 / $3,123.75
| Professional | | $200.01 | $1,208.78 | $3,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $337.59
| Professional | | $100.00 | $200.00 | $337.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.25 / $303.20 / $1,852.48
| Professional | | $185.25 | $303.20 | $1,852.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.68 / $1,178.46 / $2,023.02
| Professional | | $909.68 | $1,178.46 | $2,023.02 |