- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.73 / $782.73 / $782.73
| Facility | | $782.73 | $782.73 | $782.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.25 / $2,077.25 / $2,077.25
| Professional | | $2,077.25 | $2,077.25 | $2,077.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $65.00 / $70.00
| Professional | | $50.00 | $65.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.00 / $782.73 / $782.73
| Facility | | $65.00 | $782.73 | $782.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.48 / $2,077.25 / $2,077.25
| Professional | | $240.48 | $2,077.25 | $2,077.25 |