- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.33 / $450.80 / $4,208.42
| Facility | | $177.33 | $450.80 | $4,208.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $183.50 / $1,267.63
| Professional | | $176.45 | $183.50 | $1,267.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.45 / $283.20 / $563.76
| Facility | | $176.45 | $283.20 | $563.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $222.53
| Professional | | $176.45 | $176.45 | $222.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.46 / $176.45 / $225.99
| Facility | | $166.46 | $176.45 | $225.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $216.40
| Professional | | $176.45 | $176.45 | $216.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.45 / $176.45 / $215.27
| Professional | | $176.45 | $176.45 | $215.27 |