- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $4,466.84
| Professional | | $3,090.30 | $3,630.78 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,479.11
| Professional | | $1,230.27 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,019.95
| Facility | | $2,951.21 | $2,951.21 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $1,778.28
| Professional | | $741.31 | $977.24 | $1,778.28 |