- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.71 / $1,432.65 / $1,432.65
| Professional | | $1,069.71 | $1,432.65 | $1,432.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $211.75
| Facility | | $144.19 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $144.19 / $211.75
| Professional | | $122.56 | $144.19 | $211.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $211.75
| Facility | | $144.19 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $211.75
| Professional | | $144.19 | $144.19 | $211.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.24 / $1,201.02 / $1,486.16
| Professional | | $561.24 | $1,201.02 | $1,486.16 |