- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.24 / $195.09 / $199.50
| Professional | | $147.24 | $195.09 | $199.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $159.56 / $159.56
| Professional | | $145.51 | $159.56 | $159.56 |
- 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
- $130.69 / $153.77 / $153.77
| Professional | | $130.69 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.73 / $111.70 / $134.62
| Professional | | $72.73 | $111.70 | $134.62 |