- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $382.92 / $429.48
| Professional | | $183.43 | $382.92 | $429.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.00 / $473.20 / $569.55
| Professional | | $356.00 | $473.20 | $569.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.23 / $213.23 / $213.23
| Professional | | $213.23 | $213.23 | $213.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.00 / $382.92 / $497.94
| Facility | | $333.00 | $382.92 | $497.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.69 / $221.62 / $266.75
| Professional | | $184.69 | $221.62 | $266.75 |