- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.51 / $565.69 / $976.65
| Professional | | $120.51 | $565.69 | $976.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.85 / $1,176.74 / $1,398.75
| Facility | | $210.85 | $1,176.74 | $1,398.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.87 / $402.94 / $1,487.05
| Professional | | $146.87 | $402.94 | $1,487.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.50 / $488.08 / $1,352.92
| Facility | | $154.50 | $488.08 | $1,352.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.50 / $752.78 / $1,896.71
| Professional | | $179.50 | $752.78 | $1,896.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.46 / $1,361.17 / $1,716.32
| Professional | | $990.46 | $1,361.17 | $1,716.32 |