- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $512.86 / $1,000.00
| Professional | | $316.23 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $1,513.56
| Professional | | $741.31 | $1,122.02 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $1,348.96
| Professional | | $436.52 | $741.31 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $5,370.32
| Facility | | $1,288.25 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $794.33 / $1,584.89
| Professional | | $389.05 | $794.33 | $1,584.89 |