- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $213.80 / $446.68
| Professional | | $120.23 | $213.80 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $102.33 / $123.03
| Professional | | $97.72 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $123.03 / $275.42
| Professional | | $74.13 | $123.03 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $426.58 / $562.34
| Facility | | $407.38 | $426.58 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $436.52 / $851.14
| Professional | | $316.23 | $436.52 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $2,630.27
| Facility | | $912.01 | $912.01 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Professional | | $1,778.28 | $1,778.28 | $1,778.28 |