- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.49 / $505.14 / $602.16
| Professional | | $419.49 | $505.14 | $602.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.25 / $635.25 / $635.25
| Facility | | $635.25 | $635.25 | $635.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $550.00 / $550.00
| Professional | | $550.00 | $550.00 | $550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $200.00 / $200.00
| Professional | | $170.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.20 / $434.40 / $790.35
| Professional | | $335.20 | $434.40 | $790.35 |