- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.41 / $335.53 / $343.00
| Professional | | $253.41 | $335.53 | $343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.85 / $329.40 / $329.40
| Professional | | $259.85 | $329.40 | $329.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.52 / $209.52 / $290.14
| Facility | | $209.52 | $209.52 | $290.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.09 / $209.52 / $290.14
| Professional | | $178.09 | $209.52 | $290.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.83 / $285.83 / $285.83
| Professional | | $285.83 | $285.83 | $285.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.33 / $214.80 / $279.35
| Professional | | $163.33 | $214.80 | $279.35 |