- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $6,760.83 / $13,489.63
| Facility | | $977.24 | $6,760.83 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,137.96 / $6,456.54
| Professional | | $1,202.26 | $2,137.96 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $16,218.10 / $85,113.80
| Facility | | $1,995.26 | $16,218.10 | $85,113.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $4,365.16
| Professional | | $2,630.27 | $2,884.03 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $33,884.42 / $87,096.36
| Facility | | $16,218.10 | $33,884.42 | $87,096.36 |