- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.51 / $776.51 / $776.51
| Facility | | $776.51 | $776.51 | $776.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.83 / $428.20 / $682.28
| Professional | | $77.83 | $428.20 | $682.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.20 / $1,465.20 / $1,534.24
| Professional | | $1,465.20 | $1,465.20 | $1,534.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.81 / $79.81 / $79.81
| Professional | | $79.81 | $79.81 | $79.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.58 / $776.51 / $795.41
| Professional | | $422.58 | $776.51 | $795.41 |