- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.88 / $150.52 / $1,242.59
| Professional | | $137.88 | $150.52 | $1,242.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,040.82 / $1,040.82 / $1,061.34
| Facility | | $1,040.82 | $1,040.82 | $1,061.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.45 / $323.45 / $1,115.33
| Facility | | $323.45 | $323.45 | $1,115.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.36 / $297.85 / $433.82
| Professional | | $271.36 | $297.85 | $433.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.45 / $323.45 / $1,115.33
| Facility | | $323.45 | $323.45 | $1,115.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.61 / $297.85 / $433.82
| Professional | | $125.61 | $297.85 | $433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.41 / $197.48 / $869.63
| Professional | | $84.41 | $197.48 | $869.63 |