- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.36 / $112.36 / $112.36
| Professional | | $112.36 | $112.36 | $112.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $499.18 / $1,095.55 / $1,145.42
| Facility | | $499.18 | $1,095.55 | $1,145.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.65 / $177.65 / $177.65
| Facility | | $177.65 | $177.65 | $177.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.58 / $101.52 / $152.29
| Professional | | $44.58 | $101.52 | $152.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.65 / $177.65 / $177.65
| Facility | | $177.65 | $177.65 | $177.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.58 / $101.52 / $152.29
| Professional | | $44.58 | $101.52 | $152.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.97 / $63.68 / $144.60
| Professional | | $53.97 | $63.68 | $144.60 |