- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.56 / $321.83 / $321.83
| Professional | | $298.56 | $321.83 | $321.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.67 / $1,023.28 / $1,174.58
| Facility | | $788.67 | $1,023.28 | $1,174.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.46 / $364.46 / $633.76
| Professional | | $364.46 | $364.46 | $633.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.66 / $1,463.76 / $2,184.52
| Facility | | $1,242.66 | $1,463.76 | $2,184.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $379.65 / $702.24 / $709.03
| Professional | | $379.65 | $702.24 | $709.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.79 / $262.31 / $583.98
| Professional | | $113.79 | $262.31 | $583.98 |