- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.75 / $260.75 / $588.20
| Professional | | $260.75 | $260.75 | $588.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.30 / $506.30 / $506.30
| Professional | | $506.30 | $506.30 | $506.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.00 / $329.00 / $365.13
| Facility | | $329.00 | $329.00 | $365.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.00 / $329.00 / $329.00
| Professional | | $329.00 | $329.00 | $329.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.96 / $279.42 / $455.70
| Professional | | $208.96 | $279.42 | $455.70 |