- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.71 / $118.71 / $276.86
| Professional | | $118.71 | $118.71 | $276.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.00 / $316.00 / $720.00
| Professional | | $217.00 | $316.00 | $720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.24 / $276.81 / $609.09
| Professional | | $163.24 | $276.81 | $609.09 |
- 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
- $320.10 / $640.20 / $893.62
| Professional | | $320.10 | $640.20 | $893.62 |