- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $3,090.30 / $6,760.83
| Facility | | $588.84 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $630.96 / $1,230.27
| Professional | | $338.84 | $630.96 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,023.29 / $7,244.36
| Facility | | $588.84 | $1,023.29 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,479.11
| Professional | | $831.76 | $1,000.00 | $1,479.11 |
- 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 |