- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $3,108.62
| Professional | | $1,808.65 | $1,808.65 | $3,108.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.52 / $2,047.52 / $2,047.52
| Facility | | $2,047.52 | $2,047.52 | $2,047.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.27 / $2,051.33 / $3,418.88
| Facility | | $1,706.27 | $2,051.33 | $3,418.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.27 / $2,051.33 / $3,418.88
| Facility | | $1,706.27 | $2,051.33 | $3,418.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.65 / $1,808.65 / $1,808.65
| Professional | | $1,808.65 | $1,808.65 | $1,808.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.99 / $2,025.69 / $2,025.69
| Professional | | $1,791.99 | $2,025.69 | $2,025.69 |