- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $1,348.96
| Professional | | $891.25 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $1,122.02
| Professional | | $912.01 | $1,000.00 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $1,905.46
| Professional | | $1,258.93 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $954.99
| Facility | | $524.81 | $524.81 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $1,023.29
| Professional | | $524.81 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |