- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.44 / $3,390.78 / $4,773.84
| Professional | | $1,921.44 | $3,390.78 | $4,773.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.55 / $447.55 / $447.55
| Professional | | $447.55 | $447.55 | $447.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,790.48
| Facility | | $1,642.21 | $1,642.21 | $5,790.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.41 / $1,642.21 / $6,918.75
| Professional | | $513.41 | $1,642.21 | $6,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $867.16
| Professional | | $100.00 | $200.00 | $867.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.33 / $895.10 / $4,101.67
| Professional | | $671.33 | $895.10 | $4,101.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,324.44 / $3,118.73 / $5,208.63
| Professional | | $2,324.44 | $3,118.73 | $5,208.63 |