- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $229.09
| Professional | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $190.55 / $309.03
| Facility | | $123.03 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $177.83 / $263.03
| Professional | | $165.96 | $177.83 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Facility | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $912.01
| Professional | | $794.33 | $912.01 | $912.01 |