- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.90 / $146.62 / $169.10
| Professional | | $105.90 | $146.62 | $169.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $497.38 / $497.38 / $637.00
| Facility | | $497.38 | $497.38 | $637.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.83 / $191.92 / $524.72
| Professional | | $162.83 | $191.92 | $524.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.78 / $220.39 / $323.79
| Professional | | $140.78 | $220.39 | $323.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.17 / $212.40 / $323.79
| Professional | | $166.17 | $212.40 | $323.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.33 / $200.05 / $591.19
| Professional | | $162.33 | $200.05 | $591.19 |