- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.72 / $152.72 / $152.72
| Professional | | $152.72 | $152.72 | $152.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $678.42 / $1,489.41 / $1,556.48
| Facility | | $678.42 | $1,489.41 | $1,556.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.57 / $152.57 / $152.57
| Facility | | $152.57 | $152.57 | $152.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.90 / $104.90 / $137.40
| Professional | | $61.90 | $104.90 | $137.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.57 / $152.57 / $152.57
| Facility | | $152.57 | $152.57 | $152.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.90 / $104.90 / $137.40
| Professional | | $61.90 | $104.90 | $137.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.30 / $73.36 / $171.16
| Professional | | $48.30 | $73.36 | $171.16 |