- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.58 / $245.56 / $457.81
| Professional | | $195.58 | $245.56 | $457.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.00 / $287.00 / $287.00
| Facility | | $287.00 | $287.00 | $287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.00 / $584.00 / $1,070.00
| Professional | | $386.00 | $584.00 | $1,070.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.77 / $424.62 / $830.86
| Professional | | $260.77 | $424.62 | $830.86 |
- 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
- $313.51 / $674.94 / $1,049.13
| Professional | | $313.51 | $674.94 | $1,049.13 |