- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.44 / $1,744.44 / $1,744.44
| Professional | | $1,744.44 | $1,744.44 | $1,744.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.33 / $1,954.33 / $2,057.19
| Professional | | $1,810.33 | $1,954.33 | $2,057.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $1,742.33
| Facility | | $396.70 | $396.70 | $1,742.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.70 / $1,704.35 / $2,596.88
| Professional | | $396.70 | $1,704.35 | $2,596.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.43 / $1,564.94 / $9,451.79
| Facility | | $170.43 | $1,564.94 | $9,451.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.34 / $805.83 / $1,204.26
| Professional | | $514.34 | $805.83 | $1,204.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.05 / $231.73 / $442.83
| Facility | | $231.05 | $231.73 | $442.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.73 / $277.72 / $547.72
| Professional | | $231.73 | $277.72 | $547.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.47 / $805.83 / $1,204.26
| Professional | | $531.47 | $805.83 | $1,204.26 |