- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.15 / $130.15 / $200.40
| Professional | | $130.15 | $130.15 | $200.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.00 / $621.00 / $937.00
| Professional | | $384.00 | $621.00 | $937.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.03 / $245.15 / $358.29
| Professional | | $174.03 | $245.15 | $358.29 |
- 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
- $202.27 / $382.39 / $594.39
| Professional | | $202.27 | $382.39 | $594.39 |