- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.06 / $114.06 / $171.51
| Professional | | $114.06 | $114.06 | $171.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.00 / $316.00 / $474.00
| Professional | | $212.00 | $316.00 | $474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.56 / $198.84 / $341.17
| Professional | | $153.56 | $198.84 | $341.17 |
- 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
- $216.70 / $433.40 / $576.82
| Professional | | $216.70 | $433.40 | $576.82 |