- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $467.74 / $1,905.46
| Professional | | $218.78 | $467.74 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $436.52 / $870.96
| Facility | | $138.04 | $436.52 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $758.58 / $1,737.80
| Professional | | $144.54 | $758.58 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $8,709.64 / $8,709.64
| Facility | | $56.23 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |