- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $2,098.48 / $3,497.46
| Facility | | $1,500.51 | $2,098.48 | $3,497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $3,497.46
| Professional | | $1,590.54 | $1,590.54 | $3,497.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $2,098.48 / $3,497.46
| Facility | | $1,500.51 | $2,098.48 | $3,497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $3,497.46
| Professional | | $1,590.54 | $1,590.54 | $3,497.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $4,771.62
| Professional | | $1,590.54 | $1,590.54 | $4,771.62 |