- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.53 / $236.53 / $268.79
| Professional | | $236.53 | $236.53 | $268.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.23 / $344.23 / $407.44
| Facility | | $344.23 | $344.23 | $407.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.67 / $796.67 / $796.67
| Professional | | $796.67 | $796.67 | $796.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.89 / $344.23 / $407.44
| Facility | | $258.89 | $344.23 | $407.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.87 / $392.86 / $796.67
| Professional | | $325.87 | $392.86 | $796.67 |