- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.20 / $185.20 / $185.20
| Professional | | $185.20 | $185.20 | $185.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.00 / $409.00 / $613.00
| Professional | | $341.00 | $409.00 | $613.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.26 / $307.02 / $396.56
| Professional | | $222.26 | $307.02 | $396.56 |
- 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
- $249.14 / $395.73 / $661.33
| Professional | | $249.14 | $395.73 | $661.33 |