- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.28 / $196.25 / $245.32
| Professional | | $169.28 | $196.25 | $245.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.78 / $147.87 / $303.87
| Facility | | $93.78 | $147.87 | $303.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $396.65 / $396.65
| Professional | | $145.00 | $396.65 | $396.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $145.00
| Facility | | $145.00 | $145.00 | $145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.99 / $145.00 / $202.10
| Professional | | $96.99 | $145.00 | $202.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.30 / $241.30 / $241.30
| Professional | | $241.30 | $241.30 | $241.30 |