- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.42 / $6,745.05 / $8,231.02
| Facility | | $233.42 | $6,745.05 | $8,231.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $205.62 / $271.62
| Professional | | $203.58 | $205.62 | $271.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $212.20
| Professional | | $203.58 | $203.58 | $212.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $259.27
| Professional | | $203.58 | $203.58 | $259.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $287.93
| Professional | | $203.58 | $203.58 | $287.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $215.79 / $248.37
| Professional | | $203.58 | $215.79 | $248.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.37 / $218.37 / $218.37
| Professional | | $218.37 | $218.37 | $218.37 |