- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,184.28
| Facility | | $1,172.56 | $1,172.56 | $1,184.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,231.19
| Professional | | $1,172.56 | $1,172.56 | $1,231.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.89 / $290.89 / $434.16
| Facility | | $290.89 | $290.89 | $434.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.19 / $1,172.56 / $1,172.56
| Facility | | $1,106.19 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,289.82
| Professional | | $1,172.56 | $1,172.56 | $1,289.82 |