- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.13 / $3,363.54 / $5,736.66
| Facility | | $739.13 | $3,363.54 | $5,736.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $500.00 / $942.00
| Professional | | $250.00 | $500.00 | $942.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,337.58 / $10,490.12 / $12,538.72
| Facility | | $6,337.58 | $10,490.12 | $12,538.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $5,979.00 / $12,680.00
| Facility | | $3,219.00 | $5,979.00 | $12,680.00 |