- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $1,023.29
| Professional | | $575.44 | $812.83 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $588.84 / $1,000.00
| Facility | | $316.23 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $794.33 / $2,344.23
| Professional | | $489.78 | $794.33 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $676.08
| Professional | | $489.78 | $489.78 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $707.95 / $851.14
| Professional | | $3.02 | $707.95 | $851.14 |