- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,570.40 / $5,011.87
| Facility | | $1,174.90 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,202.26 / $1,479.11
| Professional | | $1,174.90 | $1,202.26 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.27 / $0.27 / $1,230.27
| Professional | | $0.27 | $0.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,659.59
| Professional | | $1,258.93 | $1,258.93 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.88 / $512.86 / $1,202.26
| Facility | | $12.88 | $512.86 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $1,288.25
| Professional | | $1,258.93 | $1,288.25 | $1,288.25 |