- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.36 / $538.36 / $26,073.90
| Facility | | $341.36 | $538.36 | $26,073.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $190.33
| Professional | | $173.03 | $173.03 | $190.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.55 / $172.55 / $206.73
| Professional | | $172.55 | $172.55 | $206.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.24 / $163.24 / $173.03
| Facility | | $163.24 | $163.24 | $173.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $213.41
| Professional | | $173.03 | $173.03 | $213.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.08 / $173.03 / $195.66
| Professional | | $147.08 | $173.03 | $195.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $183.59 / $183.59 / $183.59
| Facility | | $183.59 | $183.59 | $183.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $192.62 / $254.70
| Professional | | $173.03 | $192.62 | $254.70 |