- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.57 / $7,001.33 / $7,001.33
| Professional | | $2,527.57 | $7,001.33 | $7,001.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,671.00 / $5,123.00 / $16,907.36
| Facility | | $3,671.00 | $5,123.00 | $16,907.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.68 / $1,611.83 / $2,245.37
| Professional | | $1,506.68 | $1,611.83 | $2,245.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.80 / $1,425.81 / $2,261.23
| Professional | | $30.80 | $1,425.81 | $2,261.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.10 / $1,296.19 / $1,944.29
| Professional | | $23.10 | $1,296.19 | $1,944.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.24 / $1,540.95 / $2,444.41
| Professional | | $1,190.24 | $1,540.95 | $2,444.41 |