- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.01 / $2,016.01 / $2,415.41
| Professional | | $2,016.01 | $2,016.01 | $2,415.41 |
- 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
- $645.25 / $1,083.24 / $1,468.93
| Facility | | $645.25 | $1,083.24 | $1,468.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.84 / $1,131.84 / $1,131.84
| Professional | | $1,131.84 | $1,131.84 | $1,131.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $666.71 / $1,083.24 / $1,468.93
| Facility | | $666.71 | $1,083.24 | $1,468.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.84 / $1,131.84 / $1,131.84
| Professional | | $1,131.84 | $1,131.84 | $1,131.84 |