- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $6,606.93 / $8,128.31
| Facility | | $831.76 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $933.25 / $4,897.79
| Professional | | $575.44 | $933.25 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $8,511.38 / $28,183.83
| Facility | | $1,230.27 | $8,511.38 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,513.56 / $2,238.72
| Professional | | $1,445.44 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $30,199.52
| Facility | | $8,511.38 | $13,489.63 | $30,199.52 |