- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.00 / $195.00 / $243.75
| Professional | | $195.00 | $195.00 | $243.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.48 / $255.48 / $255.48
| Facility | | $255.48 | $255.48 | $255.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.66 / $616.66 / $616.66
| Professional | | $616.66 | $616.66 | $616.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.20 / $322.20 / $354.06
| Facility | | $322.20 | $322.20 | $354.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.20 / $354.06 / $459.86
| Professional | | $322.20 | $354.06 | $459.86 |