- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.12 / $5,860.80 / $8,087.58
| Professional | | $3,321.12 | $5,860.80 | $8,087.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.27 / $923.63 / $923.63
| Professional | | $815.27 | $923.63 | $923.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,978.93 / $4,978.93
| Facility | | $4,488.00 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,978.93 / $14,873.44
| Professional | | $4,232.09 | $4,978.93 | $14,873.44 |
- 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
- $461.82 / $1,539.38 / $4,702.70
| Professional | | $461.82 | $1,539.38 | $4,702.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,417.69 / $4,064.65 / $6,829.47
| Professional | | $2,417.69 | $4,064.65 | $6,829.47 |