- 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
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- 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
- $1,230.27 / $1,862.09 / $2,818.38
| Professional | | $1,230.27 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $5,370.32
| Facility | | $1,288.25 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,819.70 / $3,981.07
| Professional | | $1,023.29 | $1,819.70 | $3,981.07 |