- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.35 / $1,000.00 / $1,193.64
| Professional | | $809.35 | $1,000.00 | $1,193.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.45 / $818.45 / $1,037.47
| Professional | | $818.45 | $818.45 | $1,037.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.37 / $867.37 / $1,301.14
| Facility | | $867.37 | $867.37 | $1,301.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.85 / $867.37 / $890.46
| Professional | | $103.85 | $867.37 | $890.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.93 / $1,055.93 / $1,055.93
| Professional | | $1,055.93 | $1,055.93 | $1,055.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.49 / $1,000.00 / $1,193.64
| Professional | | $592.49 | $1,000.00 | $1,193.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.16 / $801.32 / $2,010.23
| Professional | | $440.16 | $801.32 | $2,010.23 |