- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $3,981.07 / $6,760.83
| Facility | | $741.31 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $537.03 / $1,122.02
| Professional | | $309.03 | $537.03 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,949.84 / $6,918.31
| Facility | | $691.83 | $1,949.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,122.02
| Professional | | $707.95 | $1,000.00 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,128.61 / $7,244.36
| Facility | | $3,019.95 | $5,128.61 | $7,244.36 |