- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.94 / $1,226.94 / $1,226.94
| Facility | | $1,226.94 | $1,226.94 | $1,226.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $381.30 / $392.62
| Professional | | $377.52 | $381.30 | $392.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.38 / $376.48 / $397.79
| Facility | | $376.38 | $376.48 | $397.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.15 / $377.52 / $377.52
| Facility | | $356.15 | $377.52 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $420.26
| Professional | | $377.52 | $377.52 | $420.26 |