- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,905.46 / $3,090.30
| Professional | | $741.31 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $691.83 / $1,000.00
| Facility | | $501.19 | $691.83 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.98 / $724.44 / $1,096.48
| Professional | | $3.98 | $724.44 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $28,840.32 / $28,840.32
| Facility | | $5,754.40 | $28,840.32 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |