- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $2,511.89 / $6,760.83
| Facility | | $446.68 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $549.54 / $831.76
| Professional | | $251.19 | $549.54 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $794.33 / $1,659.59
| Facility | | $446.68 | $794.33 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $1,000.00
| Professional | | $588.84 | $724.44 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $2,344.23
| Facility | | $1,000.00 | $1,584.89 | $2,344.23 |