- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.96 / $707.96 / $707.96
| Facility | | $707.96 | $707.96 | $707.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.20 / $422.72 / $622.04
| Professional | | $72.20 | $422.72 | $622.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.50 / $1,297.50 / $1,358.64
| Professional | | $1,297.50 | $1,297.50 | $1,358.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.69 / $70.69 / $70.69
| Professional | | $70.69 | $70.69 | $70.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.39 / $707.96 / $725.40
| Professional | | $385.39 | $707.96 | $725.40 |