- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.52 / $111.52 / $111.52
| Professional | | $111.52 | $111.52 | $111.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.94 / $628.94 / $628.94
| Facility | | $628.94 | $628.94 | $628.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.53 / $450.53 / $450.53
| Professional | | $450.53 | $450.53 | $450.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $146.79 / $450.53
| Professional | | $143.26 | $146.79 | $450.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $146.79 / $450.53
| Professional | | $143.26 | $146.79 | $450.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.37 / $153.76 / $479.25
| Professional | | $106.37 | $153.76 | $479.25 |