- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $501.19 / $588.84
| Professional | | $398.11 | $501.19 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $2,630.27
| Facility | | $1,122.02 | $1,258.93 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,548.82
| Professional | | $891.25 | $891.25 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $2,137.96 / $3,388.44
| Facility | | $177.83 | $2,137.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $138.04
| Professional | | $109.65 | $109.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $1,621.81 / $2,187.76
| Professional | | $257.04 | $1,621.81 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $173.78 / $1,862.09
| Professional | | $93.33 | $173.78 | $1,862.09 |