- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $3,388.44
| Professional | | $1,071.52 | $1,071.52 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $831.76 / $1,202.26
| Professional | | $107.15 | $831.76 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $1,905.46
| Facility | | $776.25 | $1,148.15 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $831.76 / $1,737.80
| Professional | | $79.43 | $831.76 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $575.44 / $1,047.13
| Facility | | $57.54 | $575.44 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $676.08 / $776.25
| Professional | | $616.60 | $676.08 | $776.25 |