- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.30 / $1,503.08 / $1,503.08
| Professional | | $1,122.30 | $1,503.08 | $1,503.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.68 / $1,639.62 / $1,639.62
| Professional | | $1,393.68 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Professional | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.92 / $1,436.18 / $2,006.11
| Professional | | $754.92 | $1,436.18 | $2,006.11 |