- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,290.87
| Professional | | $1,584.89 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $794.33
| Professional | | $676.08 | $676.08 | $794.33 |
- 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
- $371.54 / $501.19 / $977.24
| Professional | | $371.54 | $501.19 | $977.24 |