- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.19 / $212.68 / $332.26
| Professional | | $129.19 | $212.68 | $332.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.80 / $225.78 / $372.50
| Professional | | $141.80 | $225.78 | $372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.33 / $283.82 / $448.53
| Professional | | $196.33 | $283.82 | $448.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.56 / $310.91 / $481.35
| Professional | | $170.56 | $310.91 | $481.35 |