- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.28 / $238.28 / $238.28
| Facility | | $238.28 | $238.28 | $238.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.28 / $238.28 / $355.78
| Professional | | $238.28 | $238.28 | $355.78 |
- 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
- $238.28 / $317.95 / $487.41
| Facility | | $238.28 | $317.95 | $487.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |