- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.35 / $213.35 / $304.20
| Professional | | $213.35 | $213.35 | $304.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.00 / $394.00 / $525.00
| Professional | | $276.00 | $394.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.63 / $370.75 / $537.53
| Professional | | $265.63 | $370.75 | $537.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $3,240.48 / $3,328.00
| Facility | | $788.00 | $3,240.48 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.08 / $511.19 / $922.44
| Professional | | $301.08 | $511.19 | $922.44 |