- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $210.49 / $302.16
| Professional | | $197.62 | $210.49 | $302.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.91 / $302.91 / $302.91
| Facility | | $302.91 | $302.91 | $302.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.91 / $302.91 / $302.91
| Professional | | $302.91 | $302.91 | $302.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $378.27
| Facility | | $238.16 | $238.16 | $378.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $274.02
| Professional | | $202.44 | $238.16 | $274.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $178.85 / $327.73
| Professional | | $109.61 | $178.85 | $327.73 |