- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $34,716.83 / $34,716.83
| Facility | | $236.62 | $34,716.83 | $34,716.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $248.45
| Professional | | $236.62 | $236.62 | $248.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $260.27 / $354.93
| Facility | | $236.62 | $260.27 | $354.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $548.61
| Professional | | $236.62 | $236.62 | $548.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.22 / $233.12 / $236.62
| Facility | | $223.22 | $233.12 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $245.54
| Professional | | $236.62 | $236.62 | $245.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $260.27 / $271.61
| Professional | | $236.62 | $260.27 | $271.61 |