- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $4,073.80 / $7,762.47
| Facility | | $954.99 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $870.96 / $1,096.48
| Professional | | $549.54 | $870.96 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $1,318.26
| Professional | | $977.24 | $1,023.29 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,606.93 / $26,302.68
| Facility | | $1,023.29 | $6,606.93 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $2,187.76
| Professional | | $741.31 | $1,000.00 | $2,187.76 |