- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.42 / $317.42 / $318.52
| Facility | | $317.42 | $317.42 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $382.24
| Professional | | $318.52 | $318.52 | $382.24 |
- 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
- $318.52 / $318.52 / $318.52
| Professional | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Facility | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.52 / $318.52 / $318.52
| Professional | | $318.52 | $318.52 | $318.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.66 / $318.52 / $350.38
| Professional | | $264.66 | $318.52 | $350.38 |