- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $3,676.31
| Professional | | $1,323.35 | $1,323.35 | $3,676.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,498.13 / $1,498.13 / $1,498.13
| Facility | | $1,498.13 | $1,498.13 | $1,498.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.44 / $1,635.34 / $2,725.57
| Facility | | $1,248.44 | $1,635.34 | $2,725.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $2,725.57
| Professional | | $1,323.35 | $1,323.35 | $2,725.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.44 / $1,635.34 / $2,725.57
| Facility | | $1,248.44 | $1,635.34 | $2,725.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,323.35 / $2,725.57
| Professional | | $1,323.35 | $1,323.35 | $2,725.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $1,402.75 / $3,057.47
| Professional | | $1,323.35 | $1,402.75 | $3,057.47 |