- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.19 / $218.17 / $277.33
| Professional | | $162.19 | $218.17 | $277.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.26 / $278.41 / $386.76
| Professional | | $197.26 | $278.41 | $386.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $270.70 / $270.70 / $699.00
| Facility | | $270.70 | $270.70 | $699.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.85 / $288.39 / $501.75
| Professional | | $179.85 | $288.39 | $501.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.98 / $277.82 / $493.10
| Professional | | $201.98 | $277.82 | $493.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.19 / $218.17 / $393.03
| Professional | | $162.19 | $218.17 | $393.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.21 / $288.80 / $493.10
| Professional | | $198.21 | $288.80 | $493.10 |