- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.37 / $10.37 / $2,098.61
| Facility | | $10.37 | $10.37 | $2,098.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.67 / $1,222.67 / $1,514.65
| Professional | | $1,222.67 | $1,222.67 | $1,514.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.17 / $1,186.17 / $1,186.17
| Facility | | $1,186.17 | $1,186.17 | $1,186.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.08 / $1,365.82 / $3,616.09
| Professional | | $1,233.08 | $1,365.82 | $3,616.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,535.87 / $8,535.87 / $8,535.87
| Facility | | $8,535.87 | $8,535.87 | $8,535.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.20 / $1,491.52 / $4,014.74
| Professional | | $821.20 | $1,491.52 | $4,014.74 |