- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.58 / $84.58 / $157.19
| Professional | | $84.58 | $84.58 | $157.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.00 / $235.00 / $364.00
| Professional | | $147.00 | $235.00 | $364.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.86 / $159.22 / $253.30
| Professional | | $97.86 | $159.22 | $253.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.17 / $261.68 / $466.40
| Professional | | $180.17 | $261.68 | $466.40 |