- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.48 / $124.48 / $124.48
| Professional | | $124.48 | $124.48 | $124.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.00 / $271.00 / $396.00
| Professional | | $226.00 | $271.00 | $396.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.47 / $209.23 / $312.18
| Professional | | $171.47 | $209.23 | $312.18 |
- 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
- $217.80 / $371.00 / $514.80
| Professional | | $217.80 | $371.00 | $514.80 |