- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.33 / $165.73 / $717.30
| Professional | | $109.33 | $165.73 | $717.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.00 / $303.00 / $456.00
| Professional | | $202.00 | $303.00 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.63 / $191.93 / $328.05
| Professional | | $148.63 | $191.93 | $328.05 |
- 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
- $210.65 / $351.09 / $562.32
| Professional | | $210.65 | $351.09 | $562.32 |