- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.44 / $291.00 / $389.73
| Professional | | $226.44 | $291.00 | $389.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $465.35
| Facility | | $354.55 | $354.55 | $465.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.37 / $354.55 / $465.35
| Professional | | $301.37 | $354.55 | $465.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $465.35
| Facility | | $354.55 | $354.55 | $465.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $465.35
| Professional | | $354.55 | $354.55 | $465.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.45 / $440.66 / $603.50
| Professional | | $185.45 | $440.66 | $603.50 |