- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.44 / $97.44 / $252.82
| Professional | | $97.44 | $97.44 | $252.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $558.00 / $1,151.00
| Professional | | $288.00 | $558.00 | $1,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.54 / $192.80 / $427.67
| Professional | | $128.54 | $192.80 | $427.67 |
- 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
- $261.01 / $414.16 / $723.24
| Professional | | $261.01 | $414.16 | $723.24 |