- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.22 / $1,035.22 / $1,035.22
| Facility | | $1,035.22 | $1,035.22 | $1,035.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $334.46
| Professional | | $318.52 | $318.52 | $334.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.42 / $317.42 / $335.39
| Facility | | $317.42 | $317.42 | $335.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Professional | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Facility | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Professional | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $354.59
| Professional | | $318.52 | $318.52 | $354.59 |