- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $239.88 / $281.84
| Professional | | $186.21 | $239.88 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $4,570.88 / $8,709.64
| Facility | | $1,949.84 | $4,570.88 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $302.00 / $512.86
| Facility | | $234.42 | $302.00 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $54.95 / $54.95
| Professional | | $30.20 | $54.95 | $54.95 |