- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.27 / $1,105.80 / $1,105.80
| Professional | | $60.27 | $1,105.80 | $1,105.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $165.00 / $272.00
| Professional | | $110.00 | $165.00 | $272.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.05 / $110.29 / $189.52
| Professional | | $81.05 | $110.29 | $189.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.55 / $243.10 / $324.70
| Professional | | $121.55 | $243.10 | $324.70 |