- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,570.28 / $2,617.14
| Facility | | $1,346.65 | $1,570.28 | $2,617.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $2,617.14
| Professional | | $1,427.45 | $1,427.45 | $2,617.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.65 / $1,570.28 / $2,617.14
| Facility | | $1,346.65 | $1,570.28 | $2,617.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $2,617.14
| Professional | | $1,427.45 | $1,427.45 | $2,617.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $4,282.35
| Professional | | $1,427.45 | $1,427.45 | $4,282.35 |