- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.10 / $1,279.10 / $1,550.57
| Professional | | $1,279.10 | $1,279.10 | $1,550.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.61 / $1,536.05 / $2,274.65
| Professional | | $1,348.61 | $1,536.05 | $2,274.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.59 / $1,581.29 / $2,371.48
| Professional | | $1,211.59 | $1,581.29 | $2,371.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.31 / $1,655.38 / $2,539.44
| Professional | | $1,285.31 | $1,655.38 | $2,539.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,279.10 / $1,279.10 / $1,550.57
| Professional | | $1,279.10 | $1,279.10 | $1,550.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,905.54 / $3,905.54 / $3,905.54
| Facility | | $3,905.54 | $3,905.54 | $3,905.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.90 / $1,532.27 / $2,202.92
| Professional | | $1,064.90 | $1,532.27 | $2,202.92 |