- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.21 / $239.60 / $756.74
| Professional | | $189.21 | $239.60 | $756.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.00 / $193.00 / $193.00
| Professional | | $193.00 | $193.00 | $193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.40 / $231.30 / $460.10
| Professional | | $27.40 | $231.30 | $460.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $771.09 / $2,922.50
| Facility | | $55.00 | $771.09 | $2,922.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.09 / $1,477.06 / $2,380.44
| Professional | | $771.09 | $1,477.06 | $2,380.44 |