- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.33 / $1,105.33 / $1,105.33
| Facility | | $1,105.33 | $1,105.33 | $1,105.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.08 / $282.27 / $289.08
| Professional | | $272.08 | $282.27 | $289.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.08 / $300.43 / $317.43
| Facility | | $289.08 | $300.43 | $317.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.08 / $306.08 / $306.08
| Professional | | $306.08 | $306.08 | $306.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Facility | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Professional | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.42 / $283.42 / $283.42
| Professional | | $283.42 | $283.42 | $283.42 |