- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.87 / $140.87 / $176.86
| Professional | | $140.87 | $140.87 | $176.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.00 / $325.00 / $474.00
| Professional | | $256.00 | $325.00 | $474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.06 / $241.27 / $408.15
| Professional | | $193.06 | $241.27 | $408.15 |
- 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
- $274.45 / $443.21 / $687.74
| Professional | | $274.45 | $443.21 | $687.74 |