- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.83 / $593.22 / $818.64
| Professional | | $459.83 | $593.22 | $818.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $859.09 / $2,355.54 / $2,355.54
| Facility | | $859.09 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.09 / $2,002.21 / $2,355.54
| Professional | | $77.09 | $2,002.21 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $183.50 / $200.00
| Professional | | $100.00 | $183.50 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.85 / $116.85 / $155.81
| Professional | | $116.85 | $116.85 | $155.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.33 / $454.24 / $719.39
| Professional | | $364.33 | $454.24 | $719.39 |