- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.43 / $193.96 / $307.80
| Professional | | $193.43 | $193.96 | $307.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.00 / $458.00 / $636.00
| Professional | | $287.00 | $458.00 | $636.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.57 / $344.13 / $503.06
| Professional | | $241.57 | $344.13 | $503.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.17 / $513.00 / $887.89
| Professional | | $290.17 | $513.00 | $887.89 |