- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.26 / $483.26 / $483.26
| Facility | | $483.26 | $483.26 | $483.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.26 / $483.26 / $483.26
| Professional | | $483.26 | $483.26 | $483.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.59 / $1,299.59 / $1,299.59
| Professional | | $1,299.59 | $1,299.59 | $1,299.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.85 / $84.85 / $84.85
| Professional | | $84.85 | $84.85 | $84.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.72 / $88.07 / $154.69
| Professional | | $58.72 | $88.07 | $154.69 |