- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,691.71 / $2,819.52
| Facility | | $1,409.82 | $1,691.71 | $2,819.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,819.52
| Professional | | $1,494.41 | $1,494.41 | $2,819.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.82 / $1,691.71 / $2,819.52
| Facility | | $1,409.82 | $1,691.71 | $2,819.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $2,819.52
| Professional | | $1,494.41 | $1,494.41 | $2,819.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $4,483.22
| Professional | | $1,494.41 | $1,494.41 | $4,483.22 |