- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.04 / $368.56 / $2,107.78
| Professional | | $192.04 | $368.56 | $2,107.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.00 / $326.00 / $326.00
| Facility | | $326.00 | $326.00 | $326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.48 / $451.84 / $996.52
| Professional | | $222.48 | $451.84 | $996.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.24 / $416.83 / $805.52
| Facility | | $211.24 | $416.83 | $805.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $537.23 / $1,027.17
| Professional | | $288.00 | $537.23 | $1,027.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.01 / $695.65 / $832.92
| Professional | | $561.01 | $695.65 | $832.92 |