- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.54 / $3,205.20 / $4,412.43
| Professional | | $2,389.54 | $3,205.20 | $4,412.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.80 / $369.80 / $369.80
| Professional | | $369.80 | $369.80 | $369.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.27 / $3,626.76 / $5,715.00
| Professional | | $432.27 | $3,626.76 | $5,715.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $636.59
| Professional | | $100.00 | $200.00 | $636.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.88 / $739.59 / $3,574.61
| Professional | | $221.88 | $739.59 | $3,574.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.16 / $2,398.92 / $3,868.78
| Professional | | $1,537.16 | $2,398.92 | $3,868.78 |