- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.73 / $206.66 / $9,020.00
| Facility | | $197.73 | $206.66 | $9,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $206.33 / $206.67
| Professional | | $172.22 | $206.33 | $206.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.54 / $186.54 / $186.54
| Facility | | $186.54 | $186.54 | $186.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.59 / $186.54 / $186.54
| Professional | | $168.59 | $186.54 | $186.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.65 / $162.47 / $172.22
| Facility | | $68.65 | $162.47 | $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
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $225.68
| Professional | | $172.22 | $172.22 | $225.68 |