- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,370.32 / $7,943.28
| Facility | | $398.11 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $398.11 / $1,122.02
| Professional | | $251.19 | $398.11 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $758.58 / $8,511.38
| Facility | | $398.11 | $758.58 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $660.69 / $1,000.00
| Professional | | $588.84 | $660.69 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,606.93 / $10,232.93
| Facility | | $4,466.84 | $6,606.93 | $10,232.93 |