- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $478.63 / $724.44
| Professional | | $380.19 | $478.63 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $1,584.89
| Professional | | $776.25 | $1,174.90 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $831.76 / $1,548.82
| Professional | | $512.86 | $831.76 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $794.33 / $1,659.59
| Professional | | $446.68 | $794.33 | $1,659.59 |