- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.91 / $76.91 / $76.91
| Professional | | $76.91 | $76.91 | $76.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.00 / $181.00 / $227.00
| Professional | | $151.00 | $181.00 | $227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.03 / $130.32 / $185.36
| Professional | | $108.03 | $130.32 | $185.36 |
- 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
- $124.30 / $200.85 / $311.52
| Professional | | $124.30 | $200.85 | $311.52 |