- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.76 / $241.76 / $241.76
| Facility | | $241.76 | $241.76 | $241.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.76 / $241.76 / $269.10
| Professional | | $241.76 | $241.76 | $269.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.27 / $3,020.06 / $4,026.75
| Facility | | $1,860.27 | $3,020.06 | $4,026.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.21 / $268.47 / $440.30
| Facility | | $227.21 | $268.47 | $440.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |