- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.27 / $235.27 / $362.97
| Professional | | $235.27 | $235.27 | $362.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.00 / $541.00 / $750.00
| Professional | | $351.00 | $541.00 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.39 / $429.91 / $623.88
| Professional | | $295.39 | $429.91 | $623.88 |
- 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
- $342.92 / $608.40 / $1,086.81
| Professional | | $342.92 | $608.40 | $1,086.81 |