- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Facility | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,671.74
| Professional | | $1,393.12 | $1,393.12 | $1,671.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,393.12
| Facility | | $1,393.12 | $1,393.12 | $1,393.12 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,253.81 / $1,393.12 / $1,393.12
| Professional | | $1,253.81 | $1,393.12 | $1,393.12 |