- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.22 / $170.48 / $170.48
| Facility | | $138.22 | $170.48 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.30 / $140.16 / $170.48
| Professional | | $114.30 | $140.16 | $170.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.84 / $235.21 / $415.44
| Professional | | $153.84 | $235.21 | $415.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.76 / $220.76 / $220.76
| Professional | | $220.76 | $220.76 | $220.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.22 / $183.89 / $412.56
| Facility | | $138.22 | $183.89 | $412.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.34 / $1,307.34 / $1,307.34
| Professional | | $1,307.34 | $1,307.34 | $1,307.34 |