- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.69 / $1,385.69 / $1,385.69
| Professional | | $1,385.69 | $1,385.69 | $1,385.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $670.25
| Facility | | $670.25 | $670.25 | $670.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.71 / $670.25 / $690.36
| Professional | | $569.71 | $670.25 | $690.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.08 / $879.08 / $1,039.35
| Facility | | $879.08 | $879.08 | $1,039.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.25 / $946.79 / $1,328.82
| Professional | | $126.25 | $946.79 | $1,328.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.71 / $1,236.75 / $1,637.64
| Professional | | $925.71 | $1,236.75 | $1,637.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.08 / $879.08 / $1,039.35
| Facility | | $879.08 | $879.08 | $1,039.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.71 / $670.25 / $690.36
| Professional | | $569.71 | $670.25 | $690.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.08 / $1,260.08 / $2,301.01
| Professional | | $641.08 | $1,260.08 | $2,301.01 |