- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.54 / $117.54 / $117.54
| Professional | | $117.54 | $117.54 | $117.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.17 / $1,145.42 / $1,198.76
| Facility | | $522.17 | $1,145.42 | $1,198.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.73 / $112.73 / $112.73
| Facility | | $112.73 | $112.73 | $112.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.64 / $77.23 / $106.41
| Professional | | $46.64 | $77.23 | $106.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.73 / $112.73 / $112.73
| Facility | | $112.73 | $112.73 | $112.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.64 / $77.23 / $106.41
| Professional | | $46.64 | $77.23 | $106.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.42 / $56.47 / $131.75
| Professional | | $40.42 | $56.47 | $131.75 |