- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.43 / $113.43 / $193.37
| Professional | | $113.43 | $113.43 | $193.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.00 / $462.00 / $765.00
| Professional | | $298.00 | $462.00 | $765.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.16 / $268.01 / $429.51
| Professional | | $161.16 | $268.01 | $429.51 |
- 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
- $289.30 / $510.44 / $856.66
| Professional | | $289.30 | $510.44 | $856.66 |