- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $100.00 / $251.19
| Professional | | $85.11 | $100.00 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $245.47
| Professional | | $204.17 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $169.82 / $245.47
| Professional | | $138.04 | $169.82 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $194.98 / $363.08
| Professional | | $107.15 | $194.98 | $363.08 |