- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.14 / $2,592.60 / $3,503.16
| Professional | | $1,469.14 | $2,592.60 | $3,503.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.24 / $340.48 / $340.48
| Professional | | $245.24 | $340.48 | $340.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $3,754.82
| Facility | | $2,225.05 | $2,225.05 | $3,754.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $5,261.25
| Professional | | $343.68 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $183.50 / $568.61
| Professional | | $100.00 | $183.50 | $568.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,120.41 / $3,120.41 / $3,120.41
| Professional | | $3,120.41 | $3,120.41 | $3,120.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.04 / $1,509.92 / $3,067.47
| Professional | | $1,396.04 | $1,509.92 | $3,067.47 |