- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.76 / $511.55 / $2,133.00
| Professional | | $334.76 | $511.55 | $2,133.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.12 / $1,754.27 / $4,907.67
| Facility | | $1,742.12 | $1,754.27 | $4,907.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.10 / $668.49 / $1,854.57
| Professional | | $567.10 | $668.49 | $1,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.99 / $713.38 / $1,854.57
| Professional | | $353.99 | $713.38 | $1,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.29 / $806.37 / $1,854.57
| Professional | | $562.29 | $806.37 | $1,854.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.44 / $707.18 / $2,276.28
| Professional | | $538.44 | $707.18 | $2,276.28 |