- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.61 / $50.61 / $162.04
| Professional | | $50.61 | $50.61 | $162.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.00 / $124.00 / $378.00
| Professional | | $99.00 | $124.00 | $378.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.94 / $121.57 / $284.68
| Professional | | $70.94 | $121.57 | $284.68 |
- 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
- $191.40 / $382.81 / $496.31
| Professional | | $191.40 | $382.81 | $496.31 |