- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.43 / $369.44 / $369.44
| Professional | | $336.43 | $369.44 | $369.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.60 / $418.60 / $625.60
| Professional | | $372.60 | $418.60 | $625.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.50 / $168.50 / $210.63
| Professional | | $168.50 | $168.50 | $210.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.00 / $722.00 / $722.00
| Professional | | $436.00 | $722.00 | $722.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.34 / $68.34 / $68.34
| Facility | | $68.34 | $68.34 | $68.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |