- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.21 / $140.21 / $140.21
| Professional | | $140.21 | $140.21 | $140.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.90 / $1,367.30 / $1,429.20
| Facility | | $622.90 | $1,367.30 | $1,429.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.52 / $134.52 / $134.52
| Facility | | $134.52 | $134.52 | $134.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.53 / $92.10 / $120.68
| Professional | | $54.53 | $92.10 | $120.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.52 / $134.52 / $134.52
| Facility | | $134.52 | $134.52 | $134.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.50 / $92.10 / $120.68
| Professional | | $21.50 | $92.10 | $120.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.11 / $67.34 / $157.12
| Professional | | $35.11 | $67.34 | $157.12 |