- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,397.02 / $3,227.10 / $4,442.49
| Professional | | $2,397.02 | $3,227.10 | $4,442.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.05 / $373.05 / $621.66
| Professional | | $373.05 | $373.05 | $621.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $435.92 / $3,657.49 / $5,767.50
| Professional | | $435.92 | $3,657.49 | $5,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $639.97
| Professional | | $100.00 | $200.00 | $639.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.83 / $746.10 / $3,585.95
| Professional | | $223.83 | $746.10 | $3,585.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.68 / $2,352.42 / $3,729.78
| Professional | | $1,550.68 | $2,352.42 | $3,729.78 |