- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $661.64 / $10,942.86 / $24,352.84
| Facility | | $661.64 | $10,942.86 | $24,352.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $205.62 / $211.73
| Professional | | $203.58 | $205.62 | $211.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.41 / $212.20 / $224.21
| Facility | | $203.41 | $212.20 | $224.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $203.58
| Professional | | $203.58 | $203.58 | $203.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.06 / $203.58 / $203.58
| Facility | | $192.06 | $203.58 | $203.58 |
- 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 / $203.58 / $226.63
| Professional | | $203.58 | $203.58 | $226.63 |