- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.73 / $413.26 / $11,043.08
| Facility | | $211.73 | $413.26 | $11,043.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $211.80 / $279.57
| Professional | | $203.58 | $211.80 | $279.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.58 / $335.91 / $647.28
| Facility | | $203.58 | $335.91 | $647.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $219.86
| Professional | | $203.58 | $203.58 | $219.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.06 / $203.58 / $207.07
| Facility | | $192.06 | $203.58 | $207.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $203.58
| Professional | | $203.58 | $203.58 | $203.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $215.79 / $264.64
| Professional | | $203.58 | $215.79 | $264.64 |