- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.93 / $1,482.18 / $2,045.34
| Professional | | $794.93 | $1,482.18 | $2,045.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.65 / $194.65 / $194.65
| Professional | | $194.65 | $194.65 | $194.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $2,146.60
| Facility | | $192.60 | $1,436.52 | $2,146.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.04 / $1,436.52 / $3,759.38
| Professional | | $1,221.04 | $1,436.52 | $3,759.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $325.06
| Professional | | $100.00 | $200.00 | $325.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.38 / $291.98 / $1,783.78
| Professional | | $178.38 | $291.98 | $1,783.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.99 / $1,135.04 / $2,011.07
| Professional | | $875.99 | $1,135.04 | $2,011.07 |