- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $2,636.23
| Professional | | $151.16 | $151.16 | $2,636.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.61 / $179.25 / $298.74
| Facility | | $142.61 | $179.25 | $298.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $298.74
| Professional | | $151.16 | $151.16 | $298.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.61 / $179.25 / $298.74
| Facility | | $142.61 | $179.25 | $298.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $298.74
| Professional | | $151.16 | $151.16 | $298.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $453.51
| Professional | | $151.16 | $151.16 | $453.51 |