- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.11 / $635.04 / $50,462.77
| Facility | | $225.11 | $635.04 | $50,462.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $225.11
| Professional | | $225.11 | $225.11 | $225.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $344.34 / $582.25
| Professional | | $225.11 | $344.34 | $582.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.37 / $212.37 / $225.11
| Facility | | $212.37 | $212.37 | $225.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.34 / $191.34 / $225.11
| Professional | | $191.34 | $191.34 | $225.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.85 / $225.11 / $364.85
| Professional | | $204.85 | $225.11 | $364.85 |