- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.23 / $3,075.23 / $3,075.23
| Professional | | $3,075.23 | $3,075.23 | $3,075.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.53 / $389.53 / $4,484.39
| Professional | | $389.53 | $389.53 | $4,484.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.36 / $497.27 / $1,463.85
| Facility | | $298.36 | $497.27 | $1,463.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.53 / $508.97 / $771.14
| Professional | | $389.53 | $508.97 | $771.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.94 / $226.76 / $2,096.52
| Professional | | $204.94 | $226.76 | $2,096.52 |