- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.40 / $338.40 / $338.40
| Facility | | $338.40 | $338.40 | $338.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.32 / $259.76 / $338.40
| Professional | | $258.32 | $259.76 | $338.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.27 / $679.27 / $679.27
| Professional | | $679.27 | $679.27 | $679.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.21 / $311.70 / $437.82
| Facility | | $239.21 | $311.70 | $437.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.50 / $1,712.50 / $1,712.50
| Professional | | $1,712.50 | $1,712.50 | $1,712.50 |