- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.24 / $232.91 / $352.27
| Professional | | $108.24 | $232.91 | $352.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.00 / $455.00 / $820.00
| Professional | | $236.00 | $455.00 | $820.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.55 / $287.51 / $558.02
| Professional | | $170.55 | $287.51 | $558.02 |
- 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
- $329.22 / $513.34 / $797.94
| Professional | | $329.22 | $513.34 | $797.94 |