- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $2,344.23
| Professional | | $870.96 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $2,951.21
| Professional | | $1,698.24 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,041.74
| Professional | | $1,096.48 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,819.70 / $3,019.95
| Professional | | $1,023.29 | $1,819.70 | $3,019.95 |