- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.61 / $164.70 / $177.05
| Professional | | $161.61 | $164.70 | $177.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.00 / $383.00 / $416.00
| Professional | | $287.00 | $383.00 | $416.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.51 / $210.01 / $293.39
| Professional | | $165.51 | $210.01 | $293.39 |
- 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
- $208.75 / $316.60 / $561.92
| Professional | | $208.75 | $316.60 | $561.92 |