- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.00 / $308.68 / $356.17
| Professional | | $193.00 | $308.68 | $356.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.92 / $378.92 / $613.97
| Facility | | $378.92 | $378.92 | $613.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.61 / $378.92 / $460.32
| Professional | | $276.61 | $378.92 | $460.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.92 / $378.92 / $613.97
| Facility | | $378.92 | $378.92 | $613.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.61 / $378.92 / $613.97
| Professional | | $276.61 | $378.92 | $613.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.38 / $374.71 / $731.27
| Professional | | $210.38 | $374.71 | $731.27 |