- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.83 / $215.41 / $270.47
| Professional | | $195.83 | $215.41 | $270.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.87 / $251.87 / $322.57
| Facility | | $251.87 | $251.87 | $322.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.17 / $215.17 / $215.17
| Professional | | $215.17 | $215.17 | $215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.17 / $215.17 / $215.17
| Professional | | $215.17 | $215.17 | $215.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.10 / $192.12 / $230.39
| Professional | | $0.10 | $192.12 | $230.39 |