- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $138.04 / $389.05
| Professional | | $100.00 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $95.50 / $151.36
| Professional | | $70.79 | $95.50 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $151.36 / $251.19
| Professional | | $85.11 | $151.36 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,754.40 / $7,244.36
| Facility | | $2,089.30 | $5,754.40 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $123.03 / $177.83
| Professional | | $81.28 | $123.03 | $177.83 |