- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $1,096.48
| Professional | | $1,047.13 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,318.26 / $2,137.96
| Professional | | $831.76 | $1,318.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,621.81
| Facility | | $1,230.27 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $1,621.81
| Professional | | $1,023.29 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $851.14 / $1,122.02
| Facility | | $112.20 | $851.14 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,862.09
| Professional | | $794.33 | $1,122.02 | $1,862.09 |