- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.34 / $168.34 / $235.82
| Professional | | $168.34 | $168.34 | $235.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.00 / $423.00 / $617.00
| Professional | | $307.00 | $423.00 | $617.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.27 / $292.13 / $498.67
| Professional | | $225.27 | $292.13 | $498.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.49 / $548.62 / $852.71
| Professional | | $335.49 | $548.62 | $852.71 |