- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.20 / $273.20 / $273.20
| Professional | | $273.20 | $273.20 | $273.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.11 / $211.13 / $405.35
| Facility | | $179.11 | $211.13 | $405.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.35 / $273.08 / $1,172.58
| Professional | | $177.35 | $273.08 | $1,172.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.27 / $197.91 / $209.60
| Facility | | $197.27 | $197.91 | $209.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.35 / $273.08 / $460.18
| Professional | | $177.35 | $273.08 | $460.18 |