- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.30 / $170.91 / $170.91
| Professional | | $101.30 | $170.91 | $170.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.80 / $146.80 / $146.80
| Professional | | $146.80 | $146.80 | $146.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $288.75
| Professional | | $18.44 | $153.77 | $288.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.26 / $105.37 / $170.63
| Professional | | $63.26 | $105.37 | $170.63 |