- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.02 / $152.02 / $152.02
| Professional | | $152.02 | $152.02 | $152.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.53 / $1,482.52 / $1,549.59
| Facility | | $675.53 | $1,482.52 | $1,549.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.79 / $118.12 / $147.65
| Professional | | $63.79 | $118.12 | $147.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.79 / $118.12 / $147.65
| Professional | | $63.79 | $118.12 | $147.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.25 / $73.02 / $170.38
| Professional | | $47.25 | $73.02 | $170.38 |