- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.63 / $103.63 / $103.63
| Facility | | $103.63 | $103.63 | $103.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.63 / $115.22 / $151.63
| Professional | | $103.63 | $115.22 | $151.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.22 / $127.22 / $127.22
| Facility | | $127.22 | $127.22 | $127.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.53 / $88.53 / $578.45
| Professional | | $88.53 | $88.53 | $578.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.00 / $824.00 / $824.00
| Facility | | $824.00 | $824.00 | $824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.38 / $170.18 / $246.53
| Professional | | $118.38 | $170.18 | $246.53 |