- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.87 / $240.66 / $314.20
| Professional | | $200.87 | $240.66 | $314.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Facility | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.00 / $470.00 / $711.00
| Professional | | $394.00 | $470.00 | $711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.74 / $401.73 / $694.15
| Professional | | $200.74 | $401.73 | $694.15 |
- 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
- $242.44 / $407.34 / $711.33
| Professional | | $242.44 | $407.34 | $711.33 |