- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.58 / $291.48 / $862.16
| Professional | | $195.58 | $291.48 | $862.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.57 / $372.84 / $559.26
| Professional | | $294.57 | $372.84 | $559.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.38 / $69.25 / $2,500.00
| Professional | | $67.38 | $69.25 | $2,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.92 / $898.92 / $1,404.15
| Facility | | $898.92 | $898.92 | $1,404.15 |