- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.28 / $146.58 / $162.59
| Professional | | $137.28 | $146.58 | $162.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.74 / $148.96 / $264.89
| Facility | | $104.74 | $148.96 | $264.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $275.00 / $343.75
| Professional | | $275.00 | $275.00 | $343.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.28 / $161.36 / $541.02
| Professional | | $137.28 | $161.36 | $541.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |