- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $213.80 / $275.42
| Professional | | $104.71 | $213.80 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $562.34 / $1,174.90
| Facility | | $501.19 | $562.34 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $389.05
| Professional | | $223.87 | $223.87 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $851.14 / $1,412.54
| Facility | | $177.83 | $851.14 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $794.33 / $1,071.52
| Professional | | $208.93 | $794.33 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $891.25 / $933.25
| Professional | | $208.93 | $891.25 | $933.25 |