- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.86 / $528.53 / $1,868.00
| Professional | | $326.86 | $528.53 | $1,868.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,449.06 / $1,459.17 / $4,519.12
| Facility | | $1,449.06 | $1,459.17 | $4,519.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.33 / $547.34 / $1,551.37
| Professional | | $464.33 | $547.34 | $1,551.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.40 / $749.41 / $1,551.37
| Professional | | $375.40 | $749.41 | $1,551.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.76 / $749.41 / $1,551.37
| Professional | | $594.76 | $749.41 | $1,551.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.77 / $611.49 / $1,904.13
| Professional | | $495.77 | $611.49 | $1,904.13 |