- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,698.24 / $2,041.74
| Professional | | $1,659.59 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $851.14 / $933.25
| Facility | | $794.33 | $851.14 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,041.74
| Professional | | $1,698.24 | $1,698.24 | $2,041.74 |