- 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
- $380.19 / $724.44 / $1,659.59
| Professional | | $380.19 | $724.44 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,570.40 / $8,709.64
| Facility | | $724.44 | $2,570.40 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,445.44
| Professional | | $933.25 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,309.57 / $8,912.51
| Facility | | $4,365.16 | $6,309.57 | $8,912.51 |