- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,023.29 / $1,230.27
| Professional | | $851.14 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $478.63
| Professional | | $398.11 | $398.11 | $478.63 |
- 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
- $208.93 / $281.84 / $524.81
| Professional | | $208.93 | $281.84 | $524.81 |