- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $371.54 / $1,000.00
| Professional | | $173.78 | $371.54 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,019.95
| Facility | | $2,454.71 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $1,047.13
| Professional | | $870.96 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $489.78 / $2,187.76
| Professional | | $239.88 | $489.78 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $870.96 / $1,513.56
| Professional | | $602.56 | $870.96 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $426.58 / $1,380.38
| Professional | | $194.98 | $426.58 | $1,380.38 |