- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,361.01
| Professional | | $1,237.28 | $1,237.28 | $1,361.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Facility | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.97 / $1,237.28 / $1,237.28
| Professional | | $1,055.97 | $1,237.28 | $1,237.28 |