- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.37 / $239.37 / $239.37
| Facility | | $239.37 | $239.37 | $239.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.37 / $239.37 / $1,125.84
| Professional | | $239.37 | $239.37 | $1,125.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,452.73 / $3,549.39 / $6,139.22
| Facility | | $2,452.73 | $3,549.39 | $6,139.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.37 / $394.96 / $454.80
| Facility | | $239.37 | $394.96 | $454.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.80 / $448.80 / $448.80
| Professional | | $448.80 | $448.80 | $448.80 |