- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,244.36 / $8,317.64
| Facility | | $4,265.80 | $7,244.36 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $8,317.64 / $19,054.61
| Professional | | $933.25 | $8,317.64 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $22,387.21 / $22,387.21
| Professional | | $151.36 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $28,183.83 / $53,703.18
| Facility | | $10,471.29 | $28,183.83 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $47,863.01
| Facility | | $10,471.29 | $16,218.10 | $47,863.01 |