- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $144.54 / $239.88
| Professional | | $93.33 | $144.54 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.88 / $154.88 / $154.88
| Facility | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $154.88 / $154.88
| Professional | | $131.83 | $154.88 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.30 / $91.20 / $141.25
| Facility | | $12.30 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $104.71 / $177.83
| Professional | | $70.79 | $104.71 | $177.83 |