- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.20 / $125.20 / $219.20
| Professional | | $125.20 | $125.20 | $219.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.50 / $244.50 / $244.50
| Professional | | $244.50 | $244.50 | $244.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $206.28
| Facility | | $153.77 | $153.77 | $206.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Professional | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.31 / $105.46 / $160.86
| Professional | | $77.31 | $105.46 | $160.86 |