- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Facility | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $418.35 / $418.35
| Professional | | $318.75 | $418.35 | $418.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,520.00 / $1,520.00
| Facility | | $1,520.00 | $1,520.00 | $1,520.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.81 / $707.01 / $802.75
| Facility | | $455.81 | $707.01 | $802.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.11 / $349.11 / $1,001.61
| Facility | | $289.11 | $349.11 | $1,001.61 |