- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $184.38
| Facility | | $184.38 | $184.38 | $184.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.38 / $184.38 / $221.34
| Professional | | $184.38 | $184.38 | $221.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.03 / $1,267.22 / $1,602.13
| Facility | | $1,059.03 | $1,267.22 | $1,602.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $150.00 / $345.40
| Professional | | $100.00 | $150.00 | $345.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |