- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $218.80 / $218.80
| Professional | | $218.80 | $218.80 | $218.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.43 / $231.46 / $285.47
| Professional | | $191.43 | $231.46 | $285.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.47 / $226.47 / $226.47
| Professional | | $226.47 | $226.47 | $226.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.47 / $457.47 / $457.47
| Facility | | $457.47 | $457.47 | $457.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.73 / $275.00 / $360.00
| Professional | | $225.73 | $275.00 | $360.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.00 / $255.00 / $475.65
| Facility | | $255.00 | $255.00 | $475.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.08 / $260.36 / $337.65
| Facility | | $202.08 | $260.36 | $337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.08 / $260.36 / $337.65
| Professional | | $202.08 | $260.36 | $337.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.51 / $245.90 / $306.86
| Professional | | $197.51 | $245.90 | $306.86 |