- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $77.62 / $2,818.38
| Professional | | $75.86 | $77.62 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $89.13 / $89.13
| Professional | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $190.55 / $501.19
| Facility | | $102.33 | $190.55 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $107.15 / $128.82
| Professional | | $102.33 | $107.15 | $128.82 |