- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.00 / $249.05 / $490.17
| Professional | | $177.00 | $249.05 | $490.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $292.50
| Facility | | $292.50 | $292.50 | $292.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.63 / $292.50 / $661.50
| Professional | | $248.63 | $292.50 | $661.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.04 / $473.04 / $476.36
| Professional | | $473.04 | $473.04 | $476.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.95 / $354.95 / $354.95
| Professional | | $354.95 | $354.95 | $354.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.45 / $270.91 / $341.01
| Professional | | $213.45 | $270.91 | $341.01 |