- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,583.23 / $6,323.34 / $8,725.86
| Professional | | $3,583.23 | $6,323.34 | $8,725.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.43 / $830.43 / $830.43
| Professional | | $830.43 | $830.43 | $830.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $3,704.40
| Facility | | $3,704.40 | $3,704.40 | $3,704.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.68 / $3,704.40 / $12,836.25
| Professional | | $821.68 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $200.00
| Professional | | $100.00 | $100.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.27 / $1,660.86 / $5,073.85
| Professional | | $498.27 | $1,660.86 | $5,073.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.50 / $3,649.76 / $7,672.09
| Professional | | $2,608.50 | $3,649.76 | $7,672.09 |