- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.53 / $140.32 / $140.32
| Facility | | $119.53 | $140.32 | $140.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.06 / $105.38 / $108.66
| Professional | | $89.06 | $105.38 | $108.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.41 / $1,088.41 / $1,088.41
| Facility | | $1,088.41 | $1,088.41 | $1,088.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.39 / $115.36 / $201.46
| Professional | | $74.39 | $115.36 | $201.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.29 / $141.09 / $269.92
| Professional | | $84.29 | $141.09 | $269.92 |