- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.30 / $12,312.55 / $39,785.36
| Facility | | $673.30 | $12,312.55 | $39,785.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.30 / $673.30 / $10,294.61
| Professional | | $673.30 | $673.30 | $10,294.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.88 / $6,571.00 / $28,207.23
| Facility | | $1,137.88 | $6,571.00 | $28,207.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,593.39 / $10,593.39 / $12,358.96
| Facility | | $10,593.39 | $10,593.39 | $12,358.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |