- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.78 / $1,286.78 / $1,286.78
| Facility | | $1,286.78 | $1,286.78 | $1,286.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.28 / $1,237.28 / $1,286.78
| Professional | | $1,237.28 | $1,237.28 | $1,286.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.25 / $1,237.28 / $1,237.28
| Facility | | $1,167.25 | $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
- $1,237.28 / $1,237.28 / $1,237.28
| Professional | | $1,237.28 | $1,237.28 | $1,237.28 |