- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.43 / $234.43 / $234.43
| Professional | | $234.43 | $234.43 | $234.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.00 / $608.00 / $730.00
| Professional | | $539.00 | $608.00 | $730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.61 / $361.33 / $593.95
| Professional | | $354.61 | $361.33 | $593.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.75 / $757.42 / $1,044.13
| Professional | | $310.75 | $757.42 | $1,044.13 |