- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.54 / $275.82 / $275.82
| Professional | | $198.54 | $275.82 | $275.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $404.15 / $523.62 / $970.62
| Facility | | $404.15 | $523.62 | $970.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.00 / $217.49 / $217.49
| Professional | | $206.00 | $217.49 | $217.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.50 / $229.50 / $333.99
| Facility | | $229.50 | $229.50 | $333.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.54 / $167.54 / $229.50
| Professional | | $167.54 | $167.54 | $229.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.92 / $367.92 / $367.92
| Professional | | $367.92 | $367.92 | $367.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.69 / $255.86 / $275.82
| Professional | | $204.69 | $255.86 | $275.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.13 / $226.70 / $521.33
| Professional | | $151.13 | $226.70 | $521.33 |