- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.28 / $182.28 / $182.28
| Professional | | $182.28 | $182.28 | $182.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.11 / $267.11 / $267.11
| Facility | | $267.11 | $267.11 | $267.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.69 / $227.04 / $267.11
| Professional | | $140.69 | $227.04 | $267.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.33 / $191.25 / $267.11
| Facility | | $142.33 | $191.25 | $267.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.69 / $267.11 / $375.08
| Professional | | $140.69 | $267.11 | $375.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.16 / $332.77 / $360.95
| Professional | | $294.16 | $332.77 | $360.95 |