- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.12 / $673.03 / $1,264.98
| Professional | | $495.12 | $673.03 | $1,264.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.26 / $642.26 / $642.26
| Facility | | $642.26 | $642.26 | $642.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.91 / $642.26 / $1,755.00
| Professional | | $545.91 | $642.26 | $1,755.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.41 / $2,524.41 / $2,524.41
| Professional | | $2,524.41 | $2,524.41 | $2,524.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.32 / $1,008.32 / $1,008.32
| Professional | | $1,008.32 | $1,008.32 | $1,008.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.79 / $845.63 / $1,198.51
| Professional | | $625.79 | $845.63 | $1,198.51 |