- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.60 / $275.70 / $288.33
| Professional | | $233.60 | $275.70 | $288.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $226.63
| Facility | | $226.63 | $226.63 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $192.64 / $226.63
| Professional | | $192.64 | $192.64 | $226.63 |
- 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 |