- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.19 / $185.19 / $185.19
| Professional | | $185.19 | $185.19 | $185.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.67 / $1,015.67 / $1,015.67
| Facility | | $1,015.67 | $1,015.67 | $1,015.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.34 / $267.73 / $523.09
| Professional | | $174.34 | $267.73 | $523.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.34 / $267.73 / $523.09
| Professional | | $174.34 | $267.73 | $523.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.65 / $270.86 / $554.85
| Professional | | $166.65 | $270.86 | $554.85 |