- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.97 / $72.97 / $72.97
| Professional | | $72.97 | $72.97 | $72.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.17 / $508.76 / $1,296.45
| Facility | | $341.17 | $508.76 | $1,296.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.94 / $136.94 / $349.66
| Professional | | $136.94 | $136.94 | $349.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.17 / $508.76 / $1,296.45
| Facility | | $341.17 | $508.76 | $1,296.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.76 / $214.86 / $349.66
| Professional | | $106.76 | $214.86 | $349.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.51 / $83.51 / $83.51
| Professional | | $83.51 | $83.51 | $83.51 |