- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $267.12 / $320.04
| Professional | | $252.00 | $267.12 | $320.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.42 / $19,841.28 / $19,841.28
| Facility | | $410.42 | $19,841.28 | $19,841.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.62 / $491.57 / $3,762.65
| Professional | | $329.62 | $491.57 | $3,762.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.30 / $294.30 / $456.76
| Facility | | $294.30 | $294.30 | $456.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.52 / $456.76 / $491.57
| Professional | | $287.52 | $456.76 | $491.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.30 / $338.30 / $338.30
| Professional | | $338.30 | $338.30 | $338.30 |