- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.88 / $1,401.88 / $1,401.88
| Professional | | $1,401.88 | $1,401.88 | $1,401.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.97 / $394.97 / $394.97
| Facility | | $394.97 | $394.97 | $394.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.33 / $394.97 / $406.82
| Professional | | $288.33 | $394.97 | $406.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.41 / $810.41 / $1,073.54
| Facility | | $810.41 | $810.41 | $1,073.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.78 / $1,014.31 / $1,352.45
| Professional | | $127.78 | $1,014.31 | $1,352.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.58 / $1,130.94 / $1,656.77
| Professional | | $101.58 | $1,130.94 | $1,656.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.41 / $810.41 / $1,073.54
| Facility | | $810.41 | $810.41 | $1,073.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.33 / $394.97 / $406.82
| Professional | | $288.33 | $394.97 | $406.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.73 / $1,274.06 / $2,362.37
| Professional | | $664.73 | $1,274.06 | $2,362.37 |