- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.82 / $243.82
| Facility | | $243.71 | $243.82 | $243.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $292.45
| Professional | | $243.71 | $243.71 | $292.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,571.97 / $12,829.58 / $17,259.89
| Facility | | $10,571.97 | $12,829.58 | $17,259.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Professional | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Facility | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Professional | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.15 / $243.71 / $271.30
| Professional | | $207.15 | $243.71 | $271.30 |