- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,513.56
| Professional | | $758.58 | $891.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $3,090.30
| Professional | | $1,698.24 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,454.71
| Professional | | $1,000.00 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,548.82 / $3,162.28
| Professional | | $912.01 | $1,548.82 | $3,162.28 |