- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,481.54 / $11,481.54 / $11,481.54
| Facility | | $11,481.54 | $11,481.54 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $371.54 / $3,311.31
| Professional | | $131.83 | $371.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,951.21
| Professional | | $1,318.26 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $251.19 / $2,951.21
| Professional | | $218.78 | $251.19 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $851.14 / $2,290.87
| Professional | | $208.93 | $851.14 | $2,290.87 |