- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.80 / $376.13 / $376.13
| Professional | | $366.80 | $376.13 | $376.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.52 / $289.52 / $554.05
| Professional | | $289.52 | $289.52 | $554.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.76 / $362.37 / $1,918.67
| Facility | | $251.76 | $362.37 | $1,918.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.19 / $329.03 / $476.10
| Professional | | $274.19 | $329.03 | $476.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.19 / $329.03 / $496.37
| Professional | | $274.19 | $329.03 | $496.37 |