- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,230.27 / $1,479.11
| Professional | | $1,202.26 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,412.54
| Professional | | $1,258.93 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $354.81
| Professional | | $288.40 | $288.40 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $1,621.81
| Professional | | $1,202.26 | $1,258.93 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $1,258.93 / $1,479.11
| Professional | | $288.40 | $1,258.93 | $1,479.11 |