- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.50 / $1,172.50 / $1,172.50
| Professional | | $1,172.50 | $1,172.50 | $1,172.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.78 / $1,313.56 / $1,382.70
| Professional | | $1,216.78 | $1,313.56 | $1,382.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.45 / $344.45 / $1,171.02
| Facility | | $344.45 | $344.45 | $1,171.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.45 / $1,145.66 / $1,841.73
| Professional | | $344.45 | $1,145.66 | $1,841.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.55 / $1,172.50 / $6,352.54
| Facility | | $114.55 | $1,172.50 | $6,352.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.58 / $541.69 / $810.94
| Professional | | $340.58 | $541.69 | $810.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.30 / $155.75 / $297.61
| Facility | | $155.30 | $155.75 | $297.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.75 / $186.66 / $368.13
| Professional | | $155.75 | $186.66 | $368.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.58 / $541.69 / $902.81
| Professional | | $340.58 | $541.69 | $902.81 |