- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.16 / $1,007.42 / $1,019.27
| Professional | | $948.16 | $1,007.42 | $1,019.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Facility | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.93 / $1,046.93 / $1,046.93
| Professional | | $1,046.93 | $1,046.93 | $1,046.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.42 / $1,080.43 / $1,457.56
| Facility | | $1,007.42 | $1,080.43 | $1,457.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.32 / $186.04 / $2,031.04
| Facility | | $102.32 | $186.04 | $2,031.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.20 / $1,185.20 / $1,185.20
| Professional | | $1,185.20 | $1,185.20 | $1,185.20 |