- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.36 / $262.95 / $1,150.15
| Professional | | $210.36 | $262.95 | $1,150.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.96 / $877.61 / $977.38
| Facility | | $186.96 | $877.61 | $977.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.00 / $2,108.69 / $2,108.69
| Professional | | $194.00 | $2,108.69 | $2,108.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.18 / $627.49 / $836.00
| Facility | | $484.18 | $627.49 | $836.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.00 / $627.49 / $847.77
| Professional | | $194.00 | $627.49 | $847.77 |