- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $6,606.93 / $8,128.31
| Facility | | $977.24 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $831.76 / $1,548.82
| Professional | | $501.19 | $831.76 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,737.80 / $6,606.93
| Facility | | $977.24 | $1,737.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,513.56 / $1,862.09
| Professional | | $1,230.27 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,888.44 / $7,762.47
| Facility | | $3,467.37 | $5,888.44 | $7,762.47 |