- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.52 / $78.52 / $78.52
| Professional | | $78.52 | $78.52 | $78.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.00 / $111.00 / $136.00
| Professional | | $111.00 | $111.00 | $136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.23 / $123.53 / $146.03
| Professional | | $116.23 | $123.53 | $146.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $2,427.98 / $5,606.00
| Facility | | $1,275.00 | $2,427.98 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.79 / $162.97 / $342.69
| Professional | | $102.79 | $162.97 | $342.69 |