- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.36 / $200.94 / $200.94
| Facility | | $163.36 | $200.94 | $200.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.72 / $163.36 / $200.94
| Professional | | $146.72 | $163.36 | $200.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.42 / $159.69 / $226.39
| Professional | | $65.42 | $159.69 | $226.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.40 / $163.40 / $163.40
| Professional | | $163.40 | $163.40 | $163.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.11 / $200.94 / $417.96
| Facility | | $136.11 | $200.94 | $417.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.42 / $1,053.42 / $1,053.42
| Professional | | $1,053.42 | $1,053.42 | $1,053.42 |