- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $117.25 / $117.25
| Professional | | $117.25 | $117.25 | $117.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.92 / $1,143.71 / $1,195.28
| Facility | | $520.92 | $1,143.71 | $1,195.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.50 / $112.50 / $112.50
| Facility | | $112.50 | $112.50 | $112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.54 / $77.23 / $96.54
| Professional | | $37.54 | $77.23 | $96.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.50 / $112.50 / $112.50
| Facility | | $112.50 | $112.50 | $112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.54 / $77.23 / $96.54
| Professional | | $37.54 | $77.23 | $96.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $56.33 / $131.43
| Professional | | $29.36 | $56.33 | $131.43 |