- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.84 / $124.84 / $124.84
| Professional | | $124.84 | $124.84 | $124.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.00 / $305.00 / $490.00
| Professional | | $254.00 | $305.00 | $490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.34 / $204.17 / $305.27
| Professional | | $166.34 | $204.17 | $305.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.35 / $312.08 / $495.00
| Professional | | $185.35 | $312.08 | $495.00 |