- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.80 / $308.68 / $308.68
| Facility | | $306.80 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $527.69
| Professional | | $308.68 | $308.68 | $527.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,399.81 / $25,969.67 / $34,937.53
| Facility | | $21,399.81 | $25,969.67 | $34,937.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.62 / $308.68 / $308.68
| Professional | | $305.62 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Facility | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $358.30
| Professional | | $308.68 | $308.68 | $358.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.92 / $308.68 / $308.68
| Professional | | $293.92 | $308.68 | $308.68 |