- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $575.44 / $776.25
| Professional | | $316.23 | $575.44 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $5,888.44
| Facility | | $2,570.40 | $2,570.40 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $371.54 / $1,148.15
| Professional | | $169.82 | $371.54 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $478.63 / $1,778.28
| Professional | | $275.42 | $478.63 | $1,778.28 |