- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,513.56
| Professional | | $478.63 | $602.56 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $2,290.87
| Facility | | $1,445.44 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $1,047.13
| Professional | | $389.05 | $512.86 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $758.58
| Facility | | $562.34 | $562.34 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $758.58
| Professional | | $549.54 | $549.54 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $602.56 / $1,318.26
| Facility | | $478.63 | $602.56 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $562.34 / $812.83
| Professional | | $446.68 | $562.34 | $812.83 |