- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.00 / $250.64 / $1,253.96
| Professional | | $241.00 | $250.64 | $1,253.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.58 / $258.48 / $334.65
| Professional | | $256.58 | $258.48 | $334.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.52 / $1,745.52 / $1,745.52
| Facility | | $1,745.52 | $1,745.52 | $1,745.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.50 / $329.14 / $734.42
| Professional | | $238.50 | $329.14 | $734.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.53 / $323.89 / $517.03
| Professional | | $243.53 | $323.89 | $517.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.34 / $307.88 / $479.75
| Professional | | $212.34 | $307.88 | $479.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.84 / $280.06 / $348.50
| Professional | | $190.84 | $280.06 | $348.50 |