- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.06 / $112.06 / $161.88
| Professional | | $112.06 | $112.06 | $161.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.00 / $292.00 / $438.00
| Professional | | $207.00 | $292.00 | $438.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.17 / $187.10 / $265.52
| Professional | | $118.17 | $187.10 | $265.52 |
- 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
- $149.06 / $286.32 / $401.26
| Professional | | $149.06 | $286.32 | $401.26 |