- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.29 / $119.58 / $7,447.47
| Professional | | $93.29 | $119.58 | $7,447.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,631.69 / $11,631.69 / $13,081.71
| Facility | | $11,631.69 | $11,631.69 | $13,081.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.57 / $290.25 / $7,187.68
| Professional | | $121.57 | $290.25 | $7,187.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.57 / $290.25 / $7,187.68
| Professional | | $121.57 | $290.25 | $7,187.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,888.54 / $7,511.01 / $21,143.05
| Professional | | $6,888.54 | $7,511.01 | $21,143.05 |