- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.21 / $140.21 / $140.21
| Facility | | $140.21 | $140.21 | $140.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.13 / $140.21 / $141.44
| Professional | | $92.13 | $140.21 | $141.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.30 / $1,430.30 / $1,907.06
| Facility | | $1,430.30 | $1,430.30 | $1,907.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.54 / $126.38 / $222.51
| Facility | | $79.54 | $126.38 | $222.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |