- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.10 / $771.36 / $1,083.83
| Professional | | $437.10 | $771.36 | $1,083.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.61 / $101.61 / $101.61
| Professional | | $101.61 | $101.61 | $101.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.40 / $833.40 / $1,310.66
| Facility | | $833.40 | $833.40 | $1,310.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.30 / $833.40 / $1,571.25
| Professional | | $116.30 | $833.40 | $1,571.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $136.62 / $201.48
| Professional | | $100.00 | $136.62 | $201.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.41 / $203.22 / $946.75
| Professional | | $152.41 | $203.22 | $946.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.16 / $709.81 / $1,190.88
| Professional | | $526.16 | $709.81 | $1,190.88 |