- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.05 / $152.05 / $152.05
| Facility | | $152.05 | $152.05 | $152.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.58 / $152.05 / $165.16
| Professional | | $130.58 | $152.05 | $165.16 |
- 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
- $72.89 / $152.05 / $258.49
| Facility | | $72.89 | $152.05 | $258.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |