- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.55 / $236.55 / $236.55
| Professional | | $236.55 | $236.55 | $236.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.00 / $434.00 / $521.00
| Professional | | $363.00 | $434.00 | $521.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.23 / $391.56 / $503.43
| Professional | | $289.23 | $391.56 | $503.43 |
- 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
- $323.95 / $527.04 / $834.25
| Professional | | $323.95 | $527.04 | $834.25 |