- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.10 / $335.10 / $418.88
| Professional | | $335.10 | $335.10 | $418.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.97 / $593.50 / $593.50
| Facility | | $155.97 | $593.50 | $593.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.00 / $665.33 / $665.33
| Professional | | $151.00 | $665.33 | $665.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.25 / $207.00 / $270.68
| Facility | | $164.25 | $207.00 | $270.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $257.13 / $294.27
| Professional | | $164.25 | $257.13 | $294.27 |