- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.47 / $1,011.27 / $1,264.08
| Professional | | $996.47 | $1,011.27 | $1,264.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $1,138.01 / $1,138.01
| Professional | | $150.00 | $1,138.01 | $1,138.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.22 / $979.65 / $1,301.53
| Facility | | $681.22 | $979.65 | $1,301.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.00 / $2,111.90 / $2,136.89
| Professional | | $844.00 | $2,111.90 | $2,136.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.00 / $844.00 / $844.00
| Facility | | $844.00 | $844.00 | $844.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.00 / $881.36 / $1,165.58
| Professional | | $772.00 | $881.36 | $1,165.58 |