- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.10 / $1,609.08 / $2,254.00
| Professional | | $863.10 | $1,609.08 | $2,254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.31 / $211.31 / $211.31
| Professional | | $211.31 | $211.31 | $211.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $2,330.61
| Facility | | $213.28 | $1,414.26 | $2,330.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.10 / $1,414.26 / $3,266.25
| Professional | | $209.10 | $1,414.26 | $3,266.25 |
- 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
- $316.97 / $422.63 / $2,470.13
| Professional | | $316.97 | $422.63 | $2,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.83 / $1,657.66 / $2,489.08
| Professional | | $1,194.83 | $1,657.66 | $2,489.08 |