- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $130.72 / $163.61
| Professional | | $130.72 | $130.72 | $163.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.00 / $619.00 / $775.00
| Professional | | $383.00 | $619.00 | $775.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.85 / $214.31 / $313.22
| Professional | | $164.85 | $214.31 | $313.22 |
- 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
- $169.11 / $357.70 / $533.00
| Professional | | $169.11 | $357.70 | $533.00 |