- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.42 / $80.42 / $132.84
| Professional | | $80.42 | $80.42 | $132.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $148.00 / $216.00
| Professional | | $123.00 | $148.00 | $216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.02 / $169.04 / $292.02
| Professional | | $108.02 | $169.04 | $292.02 |
- 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
- $186.45 / $314.57 / $501.59
| Professional | | $186.45 | $314.57 | $501.59 |