- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.69 / $321.69 / $321.69
| Facility | | $321.69 | $321.69 | $321.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.69 / $321.69 / $435.37
| Professional | | $321.69 | $321.69 | $435.37 |
- 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
- $321.69 / $388.93 / $614.91
| Facility | | $321.69 | $388.93 | $614.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |