- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,949.84
| Professional | | $724.44 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,000.00 / $1,230.27
| Professional | | $562.34 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $1,380.38
| Facility | | $1,122.02 | $1,258.93 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $1,380.38
| Professional | | $1,122.02 | $1,258.93 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,479.11
| Facility | | $758.58 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,000.00 / $1,513.56
| Professional | | $79.43 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,380.38
| Professional | | $933.25 | $1,202.26 | $1,380.38 |