- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $245.42 / $1,105.34
| Professional | | $196.33 | $245.42 | $1,105.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.59 / $250.59 / $250.59
| Facility | | $250.59 | $250.59 | $250.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.00 / $2,053.30 / $2,053.30
| Professional | | $916.00 | $2,053.30 | $2,053.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.00 / $452.81 / $565.71
| Facility | | $170.00 | $452.81 | $565.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.72 / $504.78 / $887.20
| Professional | | $122.72 | $504.78 | $887.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $251.20 / $1,044.09
| Professional | | $4.00 | $251.20 | $1,044.09 |