- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,000.00
| Professional | | $691.83 | $812.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,318.26
| Facility | | $831.76 | $831.76 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $891.25
| Professional | | $616.60 | $616.60 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,412.54 / $1,778.28
| Professional | | $1,318.26 | $1,412.54 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $831.76 / $1,122.02
| Facility | | $660.69 | $831.76 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,047.13 / $3,715.35
| Professional | | $602.56 | $1,047.13 | $3,715.35 |