- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.48 / $322.13 / $1,342.00
| Professional | | $264.48 | $322.13 | $1,342.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,624.65 / $2,624.65 / $3,259.94
| Facility | | $2,624.65 | $2,624.65 | $3,259.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $431.48 / $1,053.36
| Professional | | $240.00 | $431.48 | $1,053.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.08 / $431.48 / $1,053.36
| Professional | | $336.08 | $431.48 | $1,053.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.32 / $406.70 / $1,292.90
| Professional | | $367.32 | $406.70 | $1,292.90 |