- 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
- $540.96 / $540.96 / $677.60
| Professional | | $540.96 | $540.96 | $677.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.64 / $650.00 / $650.00
| Professional | | $241.64 | $650.00 | $650.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.08 / $634.23 / $1,266.47
| Facility | | $542.08 | $634.23 | $1,266.47 |
- 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 |