- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.54 / $3,202.20 / $4,408.29
| Professional | | $2,389.54 | $3,202.20 | $4,408.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.26 / $369.26 / $369.26
| Professional | | $369.26 | $369.26 | $369.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $3,621.85
| Facility | | $3,621.85 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.69 / $3,621.85 / $5,707.50
| Professional | | $431.69 | $3,621.85 | $5,707.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $636.23
| Professional | | $100.00 | $200.00 | $636.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.57 / $738.53 / $3,574.61
| Professional | | $221.57 | $738.53 | $3,574.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.92 / $2,006.55 / $3,868.78
| Professional | | $1,534.92 | $2,006.55 | $3,868.78 |