- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.30 / $206.47 / $1,803.60
| Professional | | $108.30 | $206.47 | $1,803.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.00 / $447.00 / $875.00
| Professional | | $289.00 | $447.00 | $875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.79 / $240.75 / $466.57
| Professional | | $136.79 | $240.75 | $466.57 |
- 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
- $216.01 / $390.00 / $823.66
| Professional | | $216.01 | $390.00 | $823.66 |