- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $411.15
| Facility | | $411.15 | $411.15 | $411.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $401.47 / $411.15
| Professional | | $386.96 | $401.47 | $411.15 |
- 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
- $403.08 / $403.08 / $403.08
| Professional | | $403.08 | $403.08 | $403.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $411.15
| Facility | | $411.15 | $411.15 | $411.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.15 / $411.15 / $461.46
| Professional | | $411.15 | $411.15 | $461.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.62 / $403.08 / $460.72
| Professional | | $342.62 | $403.08 | $460.72 |