- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.88 / $132.88 / $219.74
| Professional | | $132.88 | $132.88 | $219.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.00 / $427.00 / $689.00
| Professional | | $213.00 | $427.00 | $689.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.58 / $257.23 / $478.76
| Professional | | $158.58 | $257.23 | $478.76 |
- 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
- $292.06 / $512.10 / $842.16
| Professional | | $292.06 | $512.10 | $842.16 |