- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.07 / $63.07 / $151.32
| Professional | | $63.07 | $63.07 | $151.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.00 / $207.00 / $470.00
| Professional | | $104.00 | $207.00 | $470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.33 / $147.44 / $321.06
| Professional | | $82.33 | $147.44 | $321.06 |
- 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
- $195.25 / $342.78 / $563.64
| Professional | | $195.25 | $342.78 | $563.64 |