- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.59 / $126.52 / $260.50
| Professional | | $81.59 | $126.52 | $260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.00 / $348.00 / $1,022.00
| Professional | | $225.00 | $348.00 | $1,022.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.02 / $187.80 / $429.75
| Professional | | $111.02 | $187.80 | $429.75 |
- 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
- $135.01 / $247.80 / $447.15
| Professional | | $135.01 | $247.80 | $447.15 |