- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $3,981.07 / $6,760.83
| Facility | | $691.83 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $1,698.24
| Professional | | $407.38 | $616.60 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,174.90 / $8,317.64
| Facility | | $645.65 | $1,174.90 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,202.26
| Professional | | $870.96 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,606.93 / $8,912.51
| Facility | | $4,365.16 | $6,606.93 | $8,912.51 |