- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,059.24 / $1,059.24 / $1,059.24
| Facility | | $1,059.24 | $1,059.24 | $1,059.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.74 / $260.74 / $277.02
| Professional | | $260.74 | $260.74 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.02 / $287.89 / $304.19
| Facility | | $277.02 | $287.89 | $304.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.33 / $293.33 / $293.33
| Professional | | $293.33 | $293.33 | $293.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Facility | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Professional | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $271.60
| Professional | | $271.60 | $271.60 | $271.60 |