- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.35 / $2,361.65 / $3,698.08
| Professional | | $1,354.35 | $2,361.65 | $3,698.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.95 / $305.95 / $305.95
| Professional | | $305.95 | $305.95 | $305.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $4,675.53
| Facility | | $2,672.64 | $2,672.64 | $4,675.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,729.50
| Professional | | $2,271.73 | $2,672.64 | $4,729.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $407.95 / $489.54
| Professional | | $200.00 | $407.95 | $489.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,039.10 / $3,039.10 / $3,039.10
| Professional | | $3,039.10 | $3,039.10 | $3,039.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.26 / $2,047.28 / $3,706.60
| Professional | | $1,584.26 | $2,047.28 | $3,706.60 |