- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.16 / $312.16 / $312.16
| Facility | | $312.16 | $312.16 | $312.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.16 / $348.96 / $381.99
| Professional | | $312.16 | $348.96 | $381.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.16 / $2,216.51 / $3,868.86
| Facility | | $1,057.16 | $2,216.51 | $3,868.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.16 / $435.92 / $661.78
| Facility | | $312.16 | $435.92 | $661.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $3,000.00
| Professional | | $55.00 | $55.00 | $3,000.00 |