- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $4,786.30 / $7,244.36
| Facility | | $645.65 | $4,786.30 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $6,760.83 / $10,715.19
| Professional | | $426.58 | $6,760.83 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $10,000.00 / $25,703.96
| Facility | | $977.24 | $10,000.00 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $10,000.00 / $13,803.84
| Professional | | $933.25 | $10,000.00 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $13,489.63 / $28,183.83
| Facility | | $8,511.38 | $13,489.63 | $28,183.83 |