- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.50 / $167.86 / $563.00
| Professional | | $83.50 | $167.86 | $563.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.33 / $545.33 / $545.33
| Professional | | $545.33 | $545.33 | $545.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.08 / $173.71 / $545.33
| Professional | | $96.08 | $173.71 | $545.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.02 / $209.84 / $545.33
| Professional | | $125.02 | $209.84 | $545.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.75 / $207.55 / $669.33
| Professional | | $187.75 | $207.55 | $669.33 |