- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,187.60 / $1,187.60 / $1,187.60
| Facility | | $1,187.60 | $1,187.60 | $1,187.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.33 / $292.33 / $310.61
| Professional | | $292.33 | $292.33 | $310.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.61 / $316.20 / $334.10
| Facility | | $310.61 | $316.20 | $334.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.88 / $328.88 / $328.88
| Professional | | $328.88 | $328.88 | $328.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.61 / $310.61 / $310.61
| Facility | | $310.61 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.61 / $310.61 / $310.61
| Professional | | $310.61 | $310.61 | $310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.31 / $298.30 / $298.30
| Professional | | $253.31 | $298.30 | $298.30 |