- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $239.88 / $316.23
| Professional | | $229.09 | $239.88 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.51 / $2.51 / $5.01
| Professional | | $2.51 | $2.51 | $5.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.10 / $1,047.13 / $1,047.13
| Facility | | $63.10 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |