- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,778.28
| Professional | | $933.25 | $1,000.00 | $1,778.28 |
- 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
- $2,344.23 / $3,548.13 / $3,548.13
| Professional | | $2,344.23 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $2,818.38
| Professional | | $1,148.15 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,630.27 / $10,471.29
| Facility | | $1,380.38 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $3,630.78
| Professional | | $1,122.02 | $1,819.70 | $3,630.78 |