- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,448.84 / $1,448.84
| Professional | | $1,393.12 | $1,448.84 | $1,448.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $1,532.43
| Professional | | $1,393.12 | $1,393.12 | $1,532.43 |
- 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
- $1,393.12 / $1,393.12 / $1,393.12
| Professional | | $1,393.12 | $1,393.12 | $1,393.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,448.84 / $1,448.84
| Professional | | $1,393.12 | $1,448.84 | $1,448.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.12 / $1,393.12 / $2,020.02
| Professional | | $1,393.12 | $1,393.12 | $2,020.02 |