- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Professional | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.26 / $1,820.68 / $3,034.47
| Facility | | $1,314.26 | $1,820.68 | $3,034.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $3,034.47
| Professional | | $1,393.12 | $1,393.12 | $3,034.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,314.26 / $1,820.68 / $3,034.47
| Facility | | $1,314.26 | $1,820.68 | $3,034.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $3,034.47
| Professional | | $1,393.12 | $1,393.12 | $3,034.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $4,179.35
| Professional | | $1,393.12 | $1,393.12 | $4,179.35 |