- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,876.98 / $3,820.14 / $5,259.06
| Professional | | $2,876.98 | $3,820.14 | $5,259.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.36 / $438.36 / $438.36
| Professional | | $438.36 | $438.36 | $438.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,303.28 / $4,303.28 / $4,303.28
| Facility | | $4,303.28 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.91 / $4,303.28 / $6,776.25
| Professional | | $512.91 | $4,303.28 | $6,776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $761.86
| Professional | | $100.00 | $200.00 | $761.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.01 / $876.72 / $4,303.83
| Professional | | $263.01 | $876.72 | $4,303.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.44 / $2,578.01 / $4,324.97
| Professional | | $1,841.44 | $2,578.01 | $4,324.97 |