- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.74 / $125.74 / $192.53
| Professional | | $125.74 | $125.74 | $192.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.00 / $304.00 / $607.00
| Professional | | $205.00 | $304.00 | $607.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.94 / $240.65 / $430.35
| Professional | | $148.94 | $240.65 | $430.35 |
- 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
- $256.30 / $371.95 / $605.80
| Professional | | $256.30 | $371.95 | $605.80 |