- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $168.87 / $240.78
| Professional | | $107.15 | $168.87 | $240.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.52 / $219.52 / $724.94
| Professional | | $219.52 | $219.52 | $724.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.88 / $240.69 / $724.94
| Professional | | $123.88 | $240.69 | $724.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.88 / $240.69 / $724.94
| Professional | | $123.88 | $240.69 | $724.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.85 / $270.97 / $889.79
| Professional | | $227.85 | $270.97 | $889.79 |