- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.45 / $164.45 / $205.56
| Professional | | $164.45 | $164.45 | $205.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.15 / $1,035.15 / $1,035.15
| Facility | | $1,035.15 | $1,035.15 | $1,035.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.00 / $425.14 / $425.14
| Professional | | $132.00 | $425.14 | $425.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.64 / $106.64 / $175.74
| Facility | | $106.64 | $106.64 | $175.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.64 / $175.06 / $188.96
| Professional | | $106.64 | $175.06 | $188.96 |