- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.80 / $540.80 / $540.80
| Facility | | $540.80 | $540.80 | $540.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.67 / $540.80 / $540.80
| Professional | | $274.67 | $540.80 | $540.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.35 / $397.35 / $397.35
| Professional | | $397.35 | $397.35 | $397.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.91 / $394.91 / $755.01
| Facility | | $394.91 | $394.91 | $755.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.27 / $394.91 / $661.11
| Professional | | $288.27 | $394.91 | $661.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.20 / $320.95 / $485.86
| Professional | | $210.20 | $320.95 | $485.86 |