- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,003.21 / $1,003.21 / $1,003.21
| Facility | | $1,003.21 | $1,003.21 | $1,003.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $321.02
| Professional | | $308.68 | $308.68 | $321.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.80 / $306.80 / $324.16
| Facility | | $306.80 | $306.80 | $324.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $308.68 / $308.68
| Facility | | $291.20 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |