- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $1,819.70
| Professional | | $645.65 | $645.65 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $60.26 / $60.26
| Professional | | $45.71 | $60.26 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $707.95 / $1,819.70
| Facility | | $645.65 | $707.95 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |