- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.86 / $167.89 / $176.75
| Professional | | $164.86 | $167.89 | $176.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.49 / $493.49 / $632.00
| Facility | | $493.49 | $493.49 | $632.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.53 / $234.93 / $328.82
| Professional | | $160.53 | $234.93 | $328.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.54 / $217.23 / $328.82
| Professional | | $176.54 | $217.23 | $328.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.57 / $206.53 / $600.39
| Professional | | $160.57 | $206.53 | $600.39 |