- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.30 / $818.42 / $14,028.79
| Professional | | $625.30 | $818.42 | $14,028.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,914.21 / $11,914.21 / $12,871.50
| Facility | | $11,914.21 | $11,914.21 | $12,871.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.88 / $13,655.38 / $32,283.77
| Professional | | $817.88 | $13,655.38 | $32,283.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.88 / $13,655.38 / $32,283.77
| Professional | | $817.88 | $13,655.38 | $32,283.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,171.16 / $14,140.21 / $39,624.71
| Professional | | $13,171.16 | $14,140.21 | $39,624.71 |