- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $69.18 / $676.08 / $3,467.37
| Facility | | $69.18 | $676.08 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $245.47 / $1,862.09
| Professional | | $128.82 | $245.47 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $186.21 / $223.87
| Professional | | $173.78 | $186.21 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,238.72
| Professional | | $2,187.76 | $2,187.76 | $2,238.72 |