- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.64 / $246.64 / $308.93
| Professional | | $246.64 | $246.64 | $308.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.00 / $1,172.00 / $1,458.00
| Professional | | $725.00 | $1,172.00 | $1,458.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.25 / $408.53 / $597.08
| Professional | | $314.25 | $408.53 | $597.08 |
- 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
- $329.70 / $610.86 / $1,082.89
| Professional | | $329.70 | $610.86 | $1,082.89 |