- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $512.86 / $1,174.90
| Professional | | $457.09 | $512.86 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $1,513.56
| Professional | | $1,047.13 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $812.83 / $1,000.00
| Professional | | $537.03 | $812.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $933.25 / $1,445.44
| Professional | | $489.78 | $933.25 | $1,445.44 |