- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.73 / $71.73 / $169.33
| Professional | | $71.73 | $71.73 | $169.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.00 / $174.00 / $400.00
| Professional | | $140.00 | $174.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.74 / $146.61 / $276.86
| Professional | | $97.74 | $146.61 | $276.86 |
- 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
- $177.65 / $308.83 / $434.27
| Professional | | $177.65 | $308.83 | $434.27 |