- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $676.08 / $1,000.00
| Professional | | $457.09 | $676.08 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,511.89
| Facility | | $2,041.74 | $2,041.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $912.01 / $2,290.87
| Professional | | $776.25 | $912.01 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $758.58 / $1,071.52
| Professional | | $501.19 | $758.58 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $2,290.87
| Professional | | $1,047.13 | $1,047.13 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $707.95 / $1,862.09
| Professional | | $549.54 | $707.95 | $1,862.09 |