- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.36 / $251.36 / $275.58
| Professional | | $251.36 | $251.36 | $275.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $747.20 / $2,670.43 / $3,085.73
| Facility | | $747.20 | $2,670.43 | $3,085.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $598.01
| Professional | | $338.84 | $338.84 | $598.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,263.48 / $3,298.10 / $5,797.86
| Facility | | $1,263.48 | $3,298.10 | $5,797.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.96 / $640.37 / $739.76
| Professional | | $352.96 | $640.37 | $739.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.27 / $290.93 / $506.49
| Professional | | $181.27 | $290.93 | $506.49 |