- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.88 / $909.41 / $1,136.77
| Professional | | $576.88 | $909.41 | $1,136.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.21 / $151.57 / $151.57
| Professional | | $112.21 | $151.57 | $151.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,422.22
| Facility | | $1,116.58 | $1,116.58 | $1,422.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.10 / $1,116.58 / $1,974.00
| Professional | | $949.10 | $1,116.58 | $1,974.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.46 / $1,193.60 / $8,011.55
| Facility | | $1,063.46 | $1,193.60 | $8,011.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.85 / $875.30 / $1,329.32
| Professional | | $572.85 | $875.30 | $1,329.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.85 / $849.20 / $1,329.32
| Professional | | $572.85 | $849.20 | $1,329.32 |