- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,510.34 / $1,510.34
| Professional | | $1,452.25 | $1,510.34 | $1,510.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,597.47
| Professional | | $1,452.25 | $1,452.25 | $1,597.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Facility | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,510.34 / $1,510.34
| Professional | | $1,452.25 | $1,510.34 | $1,510.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $2,178.38
| Professional | | $1,452.25 | $1,452.25 | $2,178.38 |