- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.77 / $5,612.04 / $8,032.80
| Facility | | $294.77 | $5,612.04 | $8,032.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $368.46
| Professional | | $368.46 | $368.46 | $368.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,624.98 / $7,624.98 / $8,295.98
| Facility | | $7,624.98 | $7,624.98 | $8,295.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.00 / $1,488.62 / $14,894.69
| Facility | | $350.00 | $1,488.62 | $14,894.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,887.20 / $12,057.98 / $22,804.29
| Facility | | $7,887.20 | $12,057.98 | $22,804.29 |