- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $5,370.32 / $7,943.28
| Facility | | $436.52 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $891.25 / $1,778.28
| Professional | | $489.78 | $891.25 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,230.27 / $6,606.93
| Facility | | $676.08 | $1,230.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,122.02 / $1,513.56
| Professional | | $1,000.00 | $1,122.02 | $1,513.56 |
- 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 |