- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.83 / $134.16 / $204.81
| Professional | | $115.83 | $134.16 | $204.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.92 / $544.92 / $544.92
| Professional | | $544.92 | $544.92 | $544.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.86 / $223.70 / $544.92
| Professional | | $147.86 | $223.70 | $544.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.86 / $223.70 / $544.92
| Professional | | $147.86 | $223.70 | $544.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.58 / $236.12 / $668.84
| Professional | | $176.58 | $236.12 | $668.84 |