- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.25 / $677.96 / $3,497.97
| Facility | | $73.25 | $677.96 | $3,497.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.07 / $161.82 / $1,844.67
| Professional | | $104.07 | $161.82 | $1,844.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.10 / $1,225.10 / $1,225.10
| Professional | | $1,225.10 | $1,225.10 | $1,225.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $143.26
| Professional | | $143.26 | $143.26 | $143.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.17 / $200.88 / $234.35
| Professional | | $174.17 | $200.88 | $234.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $2,235.31
| Professional | | $2,170.19 | $2,170.19 | $2,235.31 |