- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $575.44 / $1,000.00
| Professional | | $478.63 | $575.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,380.38
| Professional | | $977.24 | $1,288.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $691.83 / $1,023.29
| Professional | | $575.44 | $691.83 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $5,370.32
| Facility | | $1,288.25 | $1,584.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $891.25 / $1,698.24
| Professional | | $524.81 | $891.25 | $1,698.24 |