- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.78 / $1,259.78 / $1,259.78
| Professional | | $1,259.78 | $1,259.78 | $1,259.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.56 / $1,845.56 / $1,845.56
| Facility | | $1,845.56 | $1,845.56 | $1,845.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.56 / $1,845.56 / $1,845.56
| Professional | | $1,845.56 | $1,845.56 | $1,845.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.56 / $1,845.56 / $1,845.56
| Facility | | $1,845.56 | $1,845.56 | $1,845.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.56 / $2,457.00 / $2,596.69
| Professional | | $1,845.56 | $2,457.00 | $2,596.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.10 / $2,105.98 / $3,246.74
| Professional | | $1,790.10 | $2,105.98 | $3,246.74 |