- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $87.10 / $331.13
| Professional | | $75.86 | $87.10 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $194.98 / $263.03
| Professional | | $112.20 | $194.98 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $177.83 / $295.12
| Professional | | $107.15 | $177.83 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $125.89 / $257.04
| Professional | | $107.15 | $125.89 | $257.04 |