- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.18 / $205.18 / $205.18
| Professional | | $205.18 | $205.18 | $205.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.50 / $1,117.50 / $1,117.50
| Facility | | $1,117.50 | $1,117.50 | $1,117.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.38 / $281.33 / $604.09
| Professional | | $272.38 | $281.33 | $604.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.38 / $290.05 / $604.09
| Professional | | $272.38 | $290.05 | $604.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.23 / $297.37 / $454.02
| Professional | | $192.23 | $297.37 | $454.02 |