- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $2,089.30
| Professional | | $870.96 | $1,000.00 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $1,778.28
| Professional | | $776.25 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $1,995.26
| Professional | | $977.24 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $1,778.28
| Professional | | $933.25 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,454.71
| Professional | | $741.31 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $1,778.28
| Professional | | $933.25 | $1,288.25 | $1,778.28 |