- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.83 / $1,606.47 / $6,434.03
| Professional | | $1,340.83 | $1,606.47 | $6,434.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $178.00
| Professional | | $170.00 | $170.00 | $178.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.43 / $944.11 / $3,207.20
| Facility | | $477.43 | $944.11 | $3,207.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.64 / $735.64 / $735.64
| Professional | | $735.64 | $735.64 | $735.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.24 / $1,000.58 / $3,207.20
| Facility | | $523.24 | $1,000.58 | $3,207.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.64 / $735.64 / $735.64
| Professional | | $735.64 | $735.64 | $735.64 |