- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $229.09
| Professional | | $186.21 | $186.21 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $181.97 / $363.08
| Facility | | $112.20 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $416.87 / $416.87
| Professional | | $120.23 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |