- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.66 / $317.08 / $318.17
| Professional | | $264.66 | $317.08 | $318.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $2,376.94 / $2,376.94
| Facility | | $1,080.00 | $2,376.94 | $2,376.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.00 / $2,184.00 / $2,184.00
| Professional | | $2,184.00 | $2,184.00 | $2,184.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.80 / $294.06 / $498.94
| Professional | | $232.80 | $294.06 | $498.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.27 / $277.19 / $325.31
| Facility | | $261.27 | $277.19 | $325.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.82 / $277.19 / $383.55
| Professional | | $250.82 | $277.19 | $383.55 |