- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.16 / $74.16 / $74.16
| Professional | | $74.16 | $74.16 | $74.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.00 / $161.00 / $235.00
| Professional | | $134.00 | $161.00 | $235.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.46 / $124.71 / $174.98
| Professional | | $101.46 | $124.71 | $174.98 |
- 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
- $118.25 / $188.42 / $291.70
| Professional | | $118.25 | $188.42 | $291.70 |