- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.97 / $162.27 / $203.37
| Professional | | $146.97 | $162.27 | $203.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.00 / $528.00 / $716.00
| Professional | | $264.00 | $528.00 | $716.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.40 / $288.19 / $493.82
| Professional | | $201.40 | $288.19 | $493.82 |
- 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
- $302.50 / $605.00 / $850.07
| Professional | | $302.50 | $605.00 | $850.07 |