- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.26 / $142.26 / $142.26
| Facility | | $142.26 | $142.26 | $142.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.15 / $142.26 / $142.26
| Professional | | $110.15 | $142.26 | $142.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.75 / $62.75 / $91.55
| Professional | | $62.75 | $62.75 | $91.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.63 / $327.63 / $424.71
| Facility | | $327.63 | $327.63 | $424.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.82 / $376.78 / $442.30
| Professional | | $254.82 | $376.78 | $442.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.00 / $66.00 / $66.00
| Professional | | $66.00 | $66.00 | $66.00 |