- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,905.46
| Professional | | $794.33 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,202.26 / $1,621.81
| Professional | | $724.44 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $1,819.70
| Professional | | $870.96 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,584.89
| Professional | | $870.96 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,187.76
| Professional | | $933.25 | $1,318.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,584.89
| Professional | | $831.76 | $1,202.26 | $1,584.89 |