- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.33 / $520.71 / $865.91
| Professional | | $502.33 | $520.71 | $865.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,038.96 / $40,094.32 / $53,939.70
| Facility | | $33,038.96 | $40,094.32 | $53,939.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $517.65
| Professional | | $510.50 | $510.50 | $517.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $525.82
| Professional | | $510.50 | $510.50 | $525.82 |