- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.85 / $979.10 / $1,617.88
| Professional | | $645.85 | $979.10 | $1,617.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.33 / $1,250.33 / $1,562.93
| Professional | | $1,250.33 | $1,250.33 | $1,562.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.26 / $140.26 / $1,823.38
| Facility | | $140.26 | $140.26 | $1,823.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.26 / $140.26 / $1,823.38
| Professional | | $140.26 | $140.26 | $1,823.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.37 / $799.37 / $799.37
| Facility | | $799.37 | $799.37 | $799.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.52 / $799.37 / $1,016.17
| Professional | | $145.52 | $799.37 | $1,016.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.29 / $1,150.85 / $1,222.79
| Professional | | $1,128.29 | $1,150.85 | $1,222.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.37 / $799.37 / $799.37
| Facility | | $799.37 | $799.37 | $799.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.52 / $799.37 / $1,016.17
| Professional | | $145.52 | $799.37 | $1,016.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.40 / $1,103.18 / $2,157.06
| Professional | | $561.40 | $1,103.18 | $2,157.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,150.85 / $1,150.85 / $1,150.85
| Facility | | $1,150.85 | $1,150.85 | $1,150.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.85 / $1,150.85 / $1,222.79
| Professional | | $1,150.85 | $1,150.85 | $1,222.79 |