- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,778.28 / $2,290.87
| Professional | | $891.25 | $1,778.28 | $2,290.87 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $660.69 / $1,000.00
| Facility | | $489.78 | $660.69 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $1,096.48
| Professional | | $537.03 | $912.01 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $660.69 / $1,000.00
| Facility | | $478.63 | $660.69 | $1,000.00 |