- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,890.24 / $2,890.24 / $2,890.24
| Professional | | $2,890.24 | $2,890.24 | $2,890.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.55 / $203.55 / $3,024.45
| Professional | | $203.55 | $203.55 | $3,024.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,061.40 / $3,061.40 / $3,667.90
| Professional | | $3,061.40 | $3,061.40 | $3,667.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.25 / $2,513.25 / $2,513.25
| Professional | | $2,513.25 | $2,513.25 | $2,513.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,400.65 / $3,400.65 / $3,400.65
| Facility | | $3,400.65 | $3,400.65 | $3,400.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,055.57 / $2,513.25
| Professional | | $1,055.57 | $1,055.57 | $2,513.25 |