- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.35 / $245.91 / $329.35
| Professional | | $191.35 | $245.91 | $329.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.01 / $455.01 / $455.01
| Professional | | $455.01 | $455.01 | $455.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.36 / $279.36 / $382.62
| Facility | | $279.36 | $279.36 | $382.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.46 / $279.36 / $382.62
| Professional | | $237.46 | $279.36 | $382.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.36 / $279.36 / $382.62
| Facility | | $279.36 | $279.36 | $382.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.36 / $279.36 / $382.62
| Professional | | $279.36 | $279.36 | $382.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.60 / $385.04 / $510.00
| Professional | | $185.60 | $385.04 | $510.00 |