- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.25 / $222.25 / $29,093.64
| Facility | | $222.25 | $222.25 | $29,093.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.25 / $222.25 / $246.69
| Professional | | $222.25 | $222.25 | $246.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.07 / $278.07 / $278.07
| Facility | | $278.07 | $278.07 | $278.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.62 / $399.36 / $399.36
| Facility | | $300.62 | $399.36 | $399.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.36 / $399.36 / $399.36
| Professional | | $399.36 | $399.36 | $399.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.25 / $246.92 / $427.88
| Professional | | $222.25 | $246.92 | $427.88 |