- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.54 / $175.54 / $175.54
| Professional | | $175.54 | $175.54 | $175.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.00 / $413.00 / $664.00
| Professional | | $344.00 | $413.00 | $664.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.71 / $285.22 / $368.46
| Professional | | $215.71 | $285.22 | $368.46 |
- 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
- $249.70 / $400.37 / $599.28
| Professional | | $249.70 | $400.37 | $599.28 |