- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.76 / $207.76 / $207.76
| Facility | | $207.76 | $207.76 | $207.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.50 / $153.77 / $207.76
| Professional | | $101.50 | $153.77 | $207.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $141.06
| Professional | | $141.06 | $141.06 | $141.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.50 / $207.76 / $261.22
| Facility | | $144.50 | $207.76 | $261.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.13 / $197.05 / $1,105.55
| Professional | | $150.13 | $197.05 | $1,105.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.13 / $197.05 / $260.30
| Professional | | $150.13 | $197.05 | $260.30 |