- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.74 / $186.41 / $186.41
| Professional | | $111.74 | $186.41 | $186.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.31 / $166.31 / $175.50
| Facility | | $166.31 | $166.31 | $175.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.65 / $166.31 / $295.13
| Professional | | $142.65 | $166.31 | $295.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.11 / $186.41 / $321.69
| Facility | | $108.11 | $186.41 | $321.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.77 / $337.77 / $337.77
| Professional | | $337.77 | $337.77 | $337.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.00 / $155.05 / $253.93
| Professional | | $108.00 | $155.05 | $253.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.02 / $1,193.68 / $1,193.68
| Facility | | $297.02 | $1,193.68 | $1,193.68 |