- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.27 / $115.27 / $115.27
| Facility | | $115.27 | $115.27 | $115.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.27 / $162.54 / $254.17
| Professional | | $115.27 | $162.54 | $254.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.10 / $4.38 / $112.60
| Professional | | $1.10 | $4.38 | $112.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.27 / $138.32 / $348.14
| Facility | | $115.27 | $138.32 | $348.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.36 / $401.70 / $530.24
| Professional | | $321.36 | $401.70 | $530.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $254.57
| Professional | | $254.57 | $254.57 | $254.57 |