- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.47 / $649.41 / $1,055.11
| Professional | | $463.47 | $649.41 | $1,055.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,824.26 / $5,824.26 / $7,234.01
| Facility | | $5,824.26 | $5,824.26 | $7,234.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.32 / $1,035.32 / $3,225.96
| Professional | | $1,035.32 | $1,035.32 | $3,225.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.48 / $1,000.00 / $2,091.51
| Professional | | $684.48 | $1,000.00 | $2,091.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.73 / $1,014.03 / $2,091.51
| Professional | | $724.73 | $1,014.03 | $2,091.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.15 / $1,313.65 / $2,238.21
| Professional | | $913.15 | $1,313.65 | $2,238.21 |