- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.10 / $699.10 / $699.10
| Facility | | $699.10 | $699.10 | $699.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.10 / $699.10 / $699.10
| Professional | | $699.10 | $699.10 | $699.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.10 / $699.10 / $699.10
| Facility | | $699.10 | $699.10 | $699.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.93 / $433.93 / $699.10
| Professional | | $433.93 | $433.93 | $699.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.07 / $87.07 / $207.31
| Professional | | $87.07 | $87.07 | $207.31 |