- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.60 / $209.70 / $3,733.50
| Professional | | $94.60 | $209.70 | $3,733.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.00 / $376.00 / $604.00
| Professional | | $243.00 | $376.00 | $604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $220.20 / $338.95
| Professional | | $130.72 | $220.20 | $338.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.80 / $246.00 / $506.98
| Professional | | $124.80 | $246.00 | $506.98 |