- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Facility | | $1,262.25 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.55 / $1,262.25 / $1,262.25
| Professional | | $1,232.55 | $1,262.25 | $1,262.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,361.25 / $1,361.25 / $1,361.25
| Facility | | $1,361.25 | $1,361.25 | $1,361.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.25 / $1,361.25 / $1,361.25
| Professional | | $1,361.25 | $1,361.25 | $1,361.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.30 / $1,334.30 / $1,334.30
| Facility | | $1,334.30 | $1,334.30 | $1,334.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.25 / $1,262.25 / $1,262.25
| Professional | | $1,262.25 | $1,262.25 | $1,262.25 |