- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.93 / $533.91 / $2,175.96
| Professional | | $407.93 | $533.91 | $2,175.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.09 / $1,837.09 / $1,849.91
| Facility | | $1,837.09 | $1,837.09 | $1,849.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.52 / $557.52 / $1,899.82
| Professional | | $557.52 | $557.52 | $1,899.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.73 / $714.58 / $1,899.82
| Professional | | $430.73 | $714.58 | $1,899.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.66 / $844.85 / $1,899.82
| Professional | | $577.66 | $844.85 | $1,899.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.70 / $739.41 / $2,331.81
| Professional | | $619.70 | $739.41 | $2,331.81 |