- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.44 / $388.75 / $529.61
| Professional | | $270.44 | $388.75 | $529.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.37 / $321.33 / $390.00
| Professional | | $275.37 | $321.33 | $390.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $292.50
| Facility | | $292.50 | $292.50 | $292.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.63 / $292.50 / $334.69
| Professional | | $248.63 | $292.50 | $334.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.05 / $429.43 / $2,606.76
| Facility | | $162.05 | $429.43 | $2,606.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.96 / $295.31 / $602.42
| Professional | | $207.96 | $295.31 | $602.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.96 / $295.31 / $607.79
| Professional | | $207.96 | $295.31 | $607.79 |