- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.50 / $712.50 / $712.50
| Facility | | $712.50 | $712.50 | $712.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.50 / $712.50 / $712.50
| Professional | | $712.50 | $712.50 | $712.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.40 / $671.40 / $671.40
| Professional | | $671.40 | $671.40 | $671.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.53 / $277.67 / $317.33
| Facility | | $255.53 | $277.67 | $317.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $736.38 / $920.47
| Professional | | $736.38 | $736.38 | $920.47 |