- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.16 / $158.16 / $188.61
| Professional | | $158.16 | $158.16 | $188.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.00 / $389.00 / $666.00
| Professional | | $330.00 | $389.00 | $666.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.86 / $270.94 / $367.49
| Professional | | $184.86 | $270.94 | $367.49 |
- 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
- $231.54 / $463.09 / $640.19
| Professional | | $231.54 | $463.09 | $640.19 |