- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $776.25 / $1,318.26
| Facility | | $407.38 | $776.25 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,412.54 / $2,041.74
| Facility | | $398.11 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,698.24 / $2,570.40
| Facility | | $380.19 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $50.12
| Professional | | $47.86 | $47.86 | $50.12 |