- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.61 / $136.61 / $136.61
| Facility | | $136.61 | $136.61 | $136.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.11 / $136.61 / $155.19
| Professional | | $111.11 | $136.61 | $155.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.25 / $156.30 / $196.75
| Professional | | $130.25 | $156.30 | $196.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.41 / $134.41 / $134.41
| Facility | | $134.41 | $134.41 | $134.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.26 / $134.41 / $154.66
| Professional | | $114.26 | $134.41 | $154.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.51 / $997.78 / $1,039.49
| Facility | | $288.51 | $997.78 | $1,039.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.70 / $105.67 / $142.82
| Professional | | $72.70 | $105.67 | $142.82 |