- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $562.34 / $1,000.00
| Professional | | $512.86 | $562.34 | $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
- $1,318.26 / $1,995.26 / $1,995.26
| Professional | | $1,318.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $977.24 / $1,584.89
| Professional | | $630.96 | $977.24 | $1,584.89 |
- 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
- $575.44 / $1,023.29 / $2,137.96
| Professional | | $575.44 | $1,023.29 | $2,137.96 |