- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $425.00 / $522.50
| Professional | | $375.00 | $425.00 | $522.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.89 / $437.05 / $1,196.18
| Professional | | $381.89 | $437.05 | $1,196.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.89 / $702.27 / $1,196.18
| Professional | | $407.89 | $702.27 | $1,196.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.89 / $702.27 / $1,196.18
| Professional | | $407.89 | $702.27 | $1,196.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.17 / $619.39 / $1,181.48
| Professional | | $346.17 | $619.39 | $1,181.48 |