- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $151.36 / $281.84
| Professional | | $100.00 | $151.36 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $436.52
| Professional | | $204.17 | $302.00 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $208.93 / $295.12
| Professional | | $144.54 | $208.93 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $10,471.29
| Facility | | $2,630.27 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $275.42 / $489.78
| Professional | | $165.96 | $275.42 | $489.78 |