- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $389.05 / $1,023.29
| Professional | | $380.19 | $389.05 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,202.26
| Professional | | $812.83 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $691.83 / $954.99
| Professional | | $549.54 | $691.83 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,370.32
| Facility | | $1,288.25 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $794.33 / $1,513.56
| Professional | | $489.78 | $794.33 | $1,513.56 |