- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.12 / $261.12 / $90,110.52
| Facility | | $261.12 | $261.12 | $90,110.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.12 / $261.12 / $261.12
| Professional | | $261.12 | $261.12 | $261.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.69 / $291.33 / $335.04
| Facility | | $256.69 | $291.33 | $335.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $225.11
| Professional | | $225.11 | $225.11 | $225.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.11 / $225.11 / $599.08
| Facility | | $225.11 | $225.11 | $599.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.85 / $225.11 / $225.11
| Professional | | $213.85 | $225.11 | $225.11 |