- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.22 / $268.05 / $10,048.50
| Facility | | $172.22 | $268.05 | $10,048.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $173.93 / $208.39
| Professional | | $172.22 | $173.93 | $208.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.22 / $280.37 / $547.57
| Facility | | $172.22 | $280.37 | $547.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.47 / $172.22 / $172.22
| Facility | | $162.47 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Facility | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $224.23
| Professional | | $172.22 | $172.22 | $224.23 |