- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.07 / $286.56 / $286.56
| Professional | | $251.07 | $286.56 | $286.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.67 / $301.95 / $413.60
| Professional | | $245.67 | $301.95 | $413.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.17 / $253.17 / $926.10
| Facility | | $253.17 | $253.17 | $926.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $350.00 / $379.00
| Professional | | $350.00 | $350.00 | $379.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.45 / $309.73 / $397.40
| Professional | | $265.45 | $309.73 | $397.40 |