- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.18 / $1,093.40 / $1,426.58
| Professional | | $1,065.18 | $1,093.40 | $1,426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.38 / $845.38 / $845.38
| Facility | | $845.38 | $845.38 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.57 / $718.57 / $1,287.90
| Professional | | $718.57 | $718.57 | $1,287.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.38 / $845.38 / $845.38
| Facility | | $845.38 | $845.38 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.57 / $845.38 / $1,287.90
| Professional | | $718.57 | $845.38 | $1,287.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.17 / $171.61 / $314.82
| Professional | | $45.17 | $171.61 | $314.82 |