- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Facility | | $1,172.56 | $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
- $295.55 / $295.55 / $295.55
| Professional | | $295.55 | $295.55 | $295.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.19 / $1,106.19 / $1,172.56
| Facility | | $1,106.19 | $1,106.19 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,493.35
| Professional | | $1,172.56 | $1,172.56 | $1,493.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.68 / $996.68 / $1,172.56
| Professional | | $996.68 | $996.68 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,900.46
| Professional | | $1,172.56 | $1,172.56 | $1,900.46 |