- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.45 / $166.45 / $342.90
| Professional | | $166.45 | $166.45 | $342.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.40 / $382.40 / $382.40
| Professional | | $382.40 | $382.40 | $382.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $322.58
| Facility | | $240.50 | $240.50 | $322.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Professional | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.75 / $164.78 / $271.94
| Professional | | $120.75 | $164.78 | $271.94 |