- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $362.81 / $399.10
| Professional | | $225.00 | $362.81 | $399.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.10 / $306.10 / $306.10
| Facility | | $306.10 | $306.10 | $306.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.49 / $104.49 / $130.61
| Professional | | $104.49 | $104.49 | $130.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.07 / $751.07 / $751.07
| Professional | | $751.07 | $751.07 | $751.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $362.81 / $417.24
| Professional | | $225.00 | $362.81 | $417.24 |