- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $596.30 / $596.30 / $74,933.60
| Facility | | $596.30 | $596.30 | $74,933.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.47 / $183.48 / $190.82
| Professional | | $183.47 | $183.48 | $190.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.41 / $183.41 / $193.80
| Facility | | $183.41 | $183.41 | $193.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $183.48
| Professional | | $183.48 | $183.48 | $183.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $183.48
| Facility | | $183.48 | $183.48 | $183.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $183.48
| Professional | | $183.48 | $183.48 | $183.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $204.25
| Professional | | $183.48 | $183.48 | $204.25 |