- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.09 / $145.29 / $311.68
| Professional | | $69.09 | $145.29 | $311.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.00 / $303.00 / $1,128.00
| Professional | | $196.00 | $303.00 | $1,128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.40 / $237.94 / $520.83
| Professional | | $95.40 | $237.94 | $520.83 |
- 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
- $276.80 / $509.15 / $791.43
| Professional | | $276.80 | $509.15 | $791.43 |