- 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 / $876.05
| Professional | | $540.96 | $540.96 | $876.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.29 / $3,005.71 / $4,765.84
| Facility | | $1,935.29 | $3,005.71 | $4,765.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.08 / $542.08 / $677.60
| Facility | | $542.08 | $542.08 | $677.60 |
- 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 |