- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.20 / $969.18 / $1,292.24
| Professional | | $549.20 | $969.18 | $1,292.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.54 / $127.28 / $127.28
| Professional | | $79.54 | $127.28 | $127.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,403.66
| Facility | | $1,042.44 | $1,042.44 | $1,403.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.86 / $1,042.44 / $2,090.63
| Professional | | $663.86 | $1,042.44 | $2,090.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $212.57
| Professional | | $100.00 | $200.00 | $212.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.92 / $190.92 / $254.57
| Professional | | $190.92 | $190.92 | $254.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.66 / $714.14 / $1,129.14
| Professional | | $550.66 | $714.14 | $1,129.14 |