- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $1,230.27
| Professional | | $141.25 | $173.78 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $316.23 / $1,047.13
| Facility | | $269.15 | $316.23 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Professional | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $275.42 / $575.44
| Facility | | $186.21 | $275.42 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $275.42 / $575.44
| Professional | | $186.21 | $275.42 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $316.23 / $1,047.13
| Facility | | $165.96 | $316.23 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $295.12
| Professional | | $165.96 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $77.62 / $186.21
| Professional | | $77.62 | $77.62 | $186.21 |