- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $85.11 / $275.42
| Professional | | $85.11 | $85.11 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $186.21 / $346.74
| Facility | | $79.43 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $89.13
| Professional | | $44.67 | $44.67 | $89.13 |