- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.19
| Facility | | $346.11 | $346.11 | $346.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $363.41
| Professional | | $346.11 | $346.11 | $363.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.66 / $1,813.84 / $2,440.19
| Facility | | $1,494.66 | $1,813.84 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Facility | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $360.39
| Facility | | $346.11 | $346.11 | $360.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |