- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.74 / $581.29 / $24,182.10
| Facility | | $448.74 | $581.29 | $24,182.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $209.20
| Professional | | $207.13 | $207.13 | $209.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.13 / $206.13 / $241.13
| Professional | | $206.13 | $206.13 | $241.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.40 / $195.40 / $207.13
| Facility | | $195.40 | $195.40 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $263.79
| Professional | | $207.13 | $207.13 | $263.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.06 / $198.00 / $222.75
| Professional | | $176.06 | $198.00 | $222.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $230.58 / $271.36
| Professional | | $207.13 | $230.58 | $271.36 |