- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,454.71 / $3,090.30
| Professional | | $1,096.48 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $794.33
| Facility | | $549.54 | $549.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $977.24 / $1,621.81
| Professional | | $363.08 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $691.83 / $851.14
| Professional | | $446.68 | $691.83 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $1,621.81
| Facility | | $724.44 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $1,202.26
| Professional | | $691.83 | $794.33 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,621.81
| Professional | | $691.83 | $691.83 | $1,621.81 |