- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.98 / $238.98 / $265.20
| Professional | | $227.98 | $238.98 | $265.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.13 / $180.13 / $180.13
| Facility | | $180.13 | $180.13 | $180.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.11 / $180.13 / $180.13
| Professional | | $153.11 | $180.13 | $180.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Facility | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Professional | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.47 / $357.47 / $357.47
| Professional | | $357.47 | $357.47 | $357.47 |