- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.46 / $1,219.46 / $1,219.46
| Facility | | $1,219.46 | $1,219.46 | $1,219.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,219.46
| Professional | | $1,172.56 | $1,172.56 | $1,219.46 |
- 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 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |