- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $831.76 / $1,000.00
| Professional | | $616.60 | $831.76 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $1,096.48
| Facility | | $1,023.29 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,096.48
| Professional | | $812.83 | $812.83 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,862.09
| Professional | | $1,096.48 | $1,380.38 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $776.25 / $1,096.48
| Facility | | $660.69 | $776.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,047.13 / $2,951.21
| Professional | | $489.78 | $1,047.13 | $2,951.21 |