- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,479.11
| Professional | | $562.34 | $562.34 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $1,737.80
| Professional | | $1,412.54 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,412.54
| Professional | | $831.76 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,365.16 / $5,370.32
| Facility | | $1,288.25 | $4,365.16 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,290.87
| Professional | | $741.31 | $1,148.15 | $2,290.87 |