- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.96 / $540.96 / $540.96
| Facility | | $540.96 | $540.96 | $540.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.04 / $540.96 / $876.05
| Professional | | $356.04 | $540.96 | $876.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $393.84 / $493.21 / $1,150.33
| Facility | | $393.84 | $493.21 | $1,150.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.66 / $215.83 / $215.83
| Professional | | $172.66 | $215.83 | $215.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.08 / $574.60 / $1,194.30
| Facility | | $542.08 | $574.60 | $1,194.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.40 / $1,274.40 / $1,274.40
| Professional | | $1,274.40 | $1,274.40 | $1,274.40 |