- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $173.09 / $7,145.82
| Facility | | $173.09 | $173.09 | $7,145.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $173.09 / $177.26
| Professional | | $166.83 | $173.09 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.41 / $156.41 / $166.84
| Professional | | $156.41 | $156.41 | $166.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $182.47 / $182.47
| Facility | | $177.26 | $182.47 | $182.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $212.71
| Professional | | $177.26 | $177.26 | $212.71 |