- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,754.23
| Professional | | $1,905.46 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $891.25
| Professional | | $758.58 | $758.58 | $891.25 |
- 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
- $446.68 / $602.56 / $1,071.52
| Professional | | $446.68 | $602.56 | $1,071.52 |