- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $524.81 / $1,412.54
| Professional | | $407.38 | $524.81 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $537.03 / $630.96
| Professional | | $489.78 | $537.03 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $588.84 / $1,000.00
| Professional | | $457.09 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $707.95 / $1,174.90
| Professional | | $562.34 | $707.95 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $707.95
| Facility | | $446.68 | $446.68 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $562.34 / $1,023.29
| Professional | | $407.38 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $616.60 / $977.24
| Professional | | $467.74 | $616.60 | $977.24 |