- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $5,370.32 / $7,943.28
| Facility | | $630.96 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $630.96 / $1,584.89
| Professional | | $398.11 | $630.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,122.02 / $6,606.93
| Facility | | $630.96 | $1,122.02 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,621.81
| Professional | | $812.83 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |