- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.19 / $4,846.14 / $4,846.14
| Professional | | $1,596.19 | $4,846.14 | $4,846.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.11 / $1,177.83 / $1,980.20
| Professional | | $977.11 | $1,177.83 | $1,980.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,512.67
| Professional | | $32.34 | $32.34 | $1,512.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.25 / $1,602.66 / $1,632.95
| Facility | | $1,259.25 | $1,602.66 | $1,632.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.69 / $1,575.08 / $2,273.67
| Professional | | $1,215.69 | $1,575.08 | $2,273.67 |