- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,235.94 / $6,760.83
| Facility | | $616.60 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $562.34 / $1,479.11
| Professional | | $354.81 | $562.34 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $8,317.64
| Facility | | $616.60 | $1,000.00 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $912.01 / $1,047.13
| Professional | | $794.33 | $912.01 | $1,047.13 |
- 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 |