- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.51 / $508.76 / $508.76
| Facility | | $505.51 | $508.76 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $869.48
| Professional | | $508.76 | $508.76 | $869.48 |
- 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
- $495.41 / $508.76 / $508.76
| Professional | | $495.41 | $508.76 | $508.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Facility | | $508.76 | $508.76 | $508.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $696.88
| Professional | | $508.76 | $508.76 | $696.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.76 / $508.76 / $508.76
| Professional | | $508.76 | $508.76 | $508.76 |