- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,106.01 / $1,106.01 / $1,106.01
| Facility | | $1,106.01 | $1,106.01 | $1,106.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $343.72 / $353.93
| Professional | | $340.31 | $343.72 | $353.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.91 / $339.76 / $358.99
| Facility | | $328.91 | $339.76 | $358.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Professional | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.05 / $340.31 / $466.52
| Facility | | $321.05 | $340.31 | $466.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Professional | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.12 / $340.31 / $340.31
| Professional | | $136.12 | $340.31 | $340.31 |