- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.15 / $47.15 / $47.15
| Professional | | $47.15 | $47.15 | $47.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.00 / $107.00 / $160.00
| Professional | | $89.00 | $107.00 | $160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.21 / $80.08 / $110.14
| Professional | | $63.21 | $80.08 | $110.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.48 / $118.70 / $190.06
| Professional | | $71.48 | $118.70 | $190.06 |