- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $775.47 / $775.47 / $775.47
| Facility | | $775.47 | $775.47 | $775.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.47 / $838.33 / $1,163.85
| Professional | | $775.47 | $838.33 | $1,163.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.93 / $1,296.74 / $2,800.45
| Facility | | $27.93 | $1,296.74 | $2,800.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.51 / $1,693.30 / $5,435.03
| Professional | | $456.51 | $1,693.30 | $5,435.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.52 / $597.61 / $1,728.01
| Professional | | $396.52 | $597.61 | $1,728.01 |