- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.04 / $214.04 / $271.60
| Professional | | $214.04 | $214.04 | $271.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $300.00 / $439.58
| Professional | | $240.00 | $300.00 | $439.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.10 / $238.16 / $238.16
| Facility | | $182.10 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $287.73
| Professional | | $202.44 | $238.16 | $287.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.44 / $256.85 / $478.08
| Facility | | $174.44 | $256.85 | $478.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $250.00 / $255.00
| Professional | | $250.00 | $250.00 | $255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.02 / $174.65 / $221.65
| Professional | | $114.02 | $174.65 | $221.65 |