- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.13 / $302.16 / $305.55
| Professional | | $163.13 | $302.16 | $305.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.24 / $262.24 / $262.24
| Professional | | $262.24 | $262.24 | $262.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Facility | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $382.13
| Professional | | $238.16 | $238.16 | $382.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $180.38 / $262.52
| Professional | | $109.61 | $180.38 | $262.52 |