- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.06 / $792.06 / $66,705.62
| Facility | | $792.06 | $792.06 | $66,705.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.82 / $255.90
| Professional | | $243.71 | $243.82 | $255.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.82 / $243.82 / $257.62
| Facility | | $243.82 | $243.82 | $257.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Professional | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Facility | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $243.71
| Professional | | $243.71 | $243.71 | $243.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.71 / $243.71 / $271.30
| Professional | | $243.71 | $243.71 | $271.30 |