- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.20 / $16,472.06 / $49,661.40
| Facility | | $212.20 | $16,472.06 | $49,661.40 |
- 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 / $212.20 / $305.37
| Facility | | $203.58 | $212.20 | $305.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.01 / $472.01 / $472.01
| Professional | | $472.01 | $472.01 | $472.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.06 / $203.58 / $210.56
| Facility | | $192.06 | $203.58 | $210.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $203.58 / $406.56
| Professional | | $203.58 | $203.58 | $406.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.58 / $215.79 / $319.92
| Professional | | $203.58 | $215.79 | $319.92 |