- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.78 / $1,974.54 / $2,685.06
| Professional | | $1,334.78 | $1,974.54 | $2,685.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.12 / $239.12 / $239.12
| Professional | | $239.12 | $239.12 | $239.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.97 / $2,225.09 / $3,768.75
| Professional | | $274.97 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $391.07
| Professional | | $100.00 | $200.00 | $391.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.47 / $478.25 / $1,996.80
| Professional | | $143.47 | $478.25 | $1,996.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.14 / $1,257.64 / $2,378.50
| Professional | | $922.14 | $1,257.64 | $2,378.50 |